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SAN JOAQUINf LVCAL HEALTH DISTRICT <br /> FFICE USE 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. l'� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. (-'r <br /> ACT STREET ADDRESS f �� CITY/TOWN <br /> GTm� ge <br /> s Name G44 e W�a <br /> Phone a - <br /> Address 9b 17 a City e <br /> Contractor's Nam License# Phan <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES !/ 0 <br /> TYPE OF WORK (Check) : NEW WELLng DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER fes. <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK &,0-' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS4 FFIELD_/ J CESSP OL/SEEPAGE PIT — OTHER --- <br /> PROPERTY LIN PRI-VATE_.DOMESTIC -WELL- - PU8L-IC. DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONSI <br /> Industria Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin <br /> -_-_Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal/' <br /> Cathodic Protection Rotary Type of Gro <br /> —,Disposal Other Other Information <br /> Surface Seal Instilled b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: <br /> (State Work Done . <br />.PUMP REPAIR: ❑State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that .th�e 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 an <br /> P y y person in such manner as to become subject to Workman's Compensation <br /> laws of, California. <br /> i WILL CALF: FOR A GROUTI SPEC N PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: -ZZ7q � <br /> D W PL PL N ON REVS SE S <br /> PHASE I <br /> FUR DEPARTMENT USE-ONLY <br /> _ <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION PHASE III FINAL. INSPECTION <br /> INSPECTION BY 'y; .' DATE �. = INSPECTION BYi <br /> 1� DATE <br />=H 14 26 Rev. 9/7845"—A �c••�u�� cdd(yo� �� �f�r�m — fx--„.,� <br />