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SAN JOAQUIN LOCALeMtALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave:; Stockton, CA 95205 Permit No.7�= <br /> !M Telephone: (k9) 466-5781 <br /> II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> iM <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 />' Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> "District. . <br /> EXACT STREET ADDRESS / - Z 5ZZ,aCITY/TOWN <br /> I <br /> Owner's Name ,�- Phone <br /> Address <br /> •vc C i ty <br /> Contractor's Name License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATI01 I!ZSURANCE ON FILE WITH SJLHD? YES !NO } <br /> TYPE OF WORK (heck) : NEW WELLDEEPEN [] RECONDITION [] DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP <br /> INSTALLATION C] PUMP REPAIR p PUMP REPLACEMENT [� � <br /> DISTANCE TO NEAREST: SEPTIC TANI�!± SEWER LINES- PIT PRIVY ---- F <br /> N SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER --�' <br /> PROPERTY LINE/JL'-fPRIVATE DOMESTIC WELLSQ' PUBLIC DOMESTIC WELL" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSfr <br /> Industrial Cable Tool Dia. of Well Excavation ry <br /> Domestic/private Drilled Dia. of Well Casing Z <br />-Domestic'/Public Driven Gauge of Casing__//Z 1�,.�r��,��1,f <br /> Irrigation Gravel Pack Depth of Grout Sea T (J J <br /> Cathodic Protection Rotary: Type of Grout <br /> DisposalOther " Other Informationle, ' <br /> Geophysical Surface Seal Instal e b : <br /> PUMP INSTALLATION: Contractor <br /> I` Type of Pump H.P. <br /> PUMP, REPLACEMENT: ' p State Work Done <br /> PUMP REPAIR: 1: ❑State Work Done I <br /> DESTRUCTION OF.I.WELL: Well Diameter Approximate Depth <br /> Describe Material 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 Localo! <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 Caljifornia." �. <br /> I WILL CALL FOR A .ROUT I EC 0 R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> II <br /> SIy <br /> TITLE: — DATE:_e <br /> M W PL T PL N ON REVER IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br />;NSPECTION BY II. DATE INSPECTION BY - DATE /15 <br />