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r � t� SAN JOAQUIN LOCAL HEALTH DI5TRIC-1 <br /> FFICE USE: ' <br /> r--� —� 1601 E. Hazelton: Ave. , Stockton, CA 95205 Permit No. <br /> ------ Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _>g' <br /> i This Permit Expires 1 .Year From Date Issued <br /> t Complete In Triplicate <br /> ,,-Application is hereby made to the San Joaquin. Local Health District fora permit �to construct <br /> `and/or install 'the work herein described. This application is made in compliance with San. . <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> "'. strict. <br /> EXACT STREET ADDRESS j"7 J <br /> CITY/TOWN L£�SCP o-it/ <br /> Owner's Name ---�� - - <br /> � M Phone <br /> Address 3 <br /> City I C_A Q� <br /> Contractor's Name ` 7 <br /> • License# 790 p Phone _�ab� <br /> _'S CERTTFICATC OF IdORKNAN'S, 0IMP£NSATIOIN I'NSURAIN ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN 0 y RECONDITION [] DESTRUCTION[� W <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 S <br /> PyMP-INSTALLATION p PUMP REPAIR® : PUMP REPLACEMENT F 3 { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA!_ FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ,- PRIVATE DOMESTIC .WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL A _ <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well 'Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> :� Domesti c/publ i c w ---�-_Driven <br /> .Irrigation' .w . y , F Gauge, of Casing------v--_ - - _ -- _ " <br /> Gravel Pack Depth of Grout Seal <br /> _Cathodic- Pro.tection�, Rotary,- _ 'Type <br /> Disposal , Other he of Grout <br /> Geophys'ieal, . � -. Other Information .� <br /> Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' <br /> PUMP REPLACEMENT: H.P. <br /> ElState Work Done <br /> PUMP REPAIR: _ -- - <br /> -State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - - � <br /> Describe. Material and Procedure Approximate Depth <br /> � v , <br /> I hereby certify that I have prepared this application and that the work will be done inaccordanc <br /> l <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations 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 permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br />[ WILL CALL FOR A GROUT INSPECTIONP IOR TO GROUTING AND A FI L INSPECTION. <br /> iIGNED <br /> TITLE: DATE: <br /> DR W L T PL N ON REVE SES DE <br />'HASE I F R DEPARTM NT USE ONLY <br />,PPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> NSP,ECTION. BY DATE PHASE III NAL INSPECTION , <br /> INSPECTION BYDATE <br /> ]426 <br />