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SAN JUAQUIN LURAL. HLALIH U15IRIUI <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 952.05 Permit No. 7 2_. i <br /> Telephone': (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year 'From Date' Issued <br /> Complete .In Triplicate <br /> Application is hereby made `to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. . This :application is made in compliance with San <br /> k2oaquin County Grdinance �Jo. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr'ct. <br /> EXACT STREET ADDRESS- SIJ. 0{�I, iz / o 1 CITY/TOW <br /> Owner's Name Phone �� �i�� <br /> AddressAl, City �7l ' <br /> Contractor' s Name -''Litens ; t L; Phone .f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> f <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION( N ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ . N <br /> PUMP INSTALLATION FJ' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 6r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />�omestic%private Drilled , Dia. of .WplI Casing_ <br /> O mesti'c/public Driven - Gau a of Casin <br /> 9 g <br /> Irrigation Gravel Patk . Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 0 r Other Information ; <br /> Geophysical Su'rfacerSeal Installed b .: <br /> PUMP INSTALLATION: Contractor rG�2 �e ` <br /> Type of Pump ( H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION 'OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Proce ure <br /> �t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance+ <br /> with San Joaquin County Ordinances , State laws , and Rules and Re'g`ulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies .the following: <br /> "I certify that in the .performance of the work for which this permi't ;is issued, I shall <br /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> laws of C lifornia." <br /> I WILL CALAR A GROUT INSPECTDCNPRIOO, GROUTING AND A4INAL INSPECTION. <br /> SIGNED Z- TITLE : _ DATE: <br /> D PLOT PLAN ON RE DE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �&Zb�/,,., OLAJ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �6 l <br />-u -1 n 7c n_.. <br />