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SAN JOAQUIN „LQCAL HEALTH DIS 1RIC1 <br /> FFICE USE: 1601 E. Hazelton ,Ave, Stockton, CA 95205 Permit NoFOR O . 7 <br /> Telephone:. • (209) 4b6.-678I Date Issued - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This. Permit Ex i res .1 `(ear .From ,tiate'. ,Issued <br /> Complete In Tri,pl icae <br /> Application is hereby made to the San Joaquin Local Health, Distric.t- for a permit:.to construct. <br /> and/or install the=work herein ;described: . This app,lication,is made in compl-iance with San , <br /> ions of the San Joaquin Local Health <br /> k'oa -,:3n County- Ordinance JNo. 1862 and the Rules and, Regulat <br /> ciI <br /> Distr. .Ct <br /> EXACT STREET ADDRESS . 7 0 4c / CITY/TOWN <br /> Owner' s Name I Phone 1221 <br /> }NI <br /> �•�+) w <br /> .. t .. / <br /> Address a <br /> . m. . ., �.ty . <br /> Contractor's Name License# ,3 Phone <br /> F + <br /> IS CERTIFICATE OF WORKMAN'S Cot.1pENSATIO"i INSURANCE ON FILE .WITH SdLHD? YES �f ad0 <br /> TYPE OF WORK (Check) NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT VU �1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> OS <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 x <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> l Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State°Work Done EIJI <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION4OF WELL: Well Diameter A roxtmate` <br /> Dapth <br /> Describe Materia and Procedure <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 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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A .FINAL INSPECTION. <br /> ` TITLE: DATE: <br /> SIGNED - DRAW PLUI PLAN ON REVERSE SIDE <br /> PHASE I t <br /> ;FOR DE RTMEN USE ONLY <br /> APPLICATION ACCEPTEDBYDATE � <br /> ADDITIONAL COMMENTS: <br /> t PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY - DATE <br />