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Or <br /> y 7A6 1110 fSRN JO�AQUIN LOCAL HEALTH DISTRICT <br /> FOR FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. — 7. <br /> ° . Telephone: (209) 466-6781 r <br /> Date Issued ► Z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permi.t Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health Distri°ctofor a permit to construct <br /> and/or install ' the work herein described. This application is made incompliance with San <br /> Joaquin County Ordinance No. 1862 and the. Rules. and Regulations of the San-Joaquin Local Health i <br /> District. �. �, � ' tfz7. <br /> EXACT STREET ADDRE55 u CITY/TOWN <br /> Phone' <br /> Owner' s Name <br /> �73 <br /> Address �► ° <br /> City <br /> Contractor's Name <br /> icense# Phone 5 `� <br /> IS CERTIFICATE OF WORKMAN' COMPENSATION I�1SJR 1ICE ON FILE WITH SJLHD? YES y NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN.[] RECONDITION ❑ DESTRUCTION❑ } <br /> WELL CHLINATION ❑ WELL ABANDONMENT ❑ <br /> OTHER 0 - <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <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 /> Domestic/private Drilled Dia. of Well Casing <br /> /p Z� <br /> Domestic/public Driven - Gauge of Casing <br /> _Irrigation x Gravel 'Pack Depth of Grout Seal — <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe b <br /> PUMP INSTALLATION: Contractor <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 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 /> 11 WILL CA4L FOR A GROU L INSPECTION PRIOR TO GROUTING AND A FI INSPECTION. <br /> SIGNED TITLE: DATE: 7' <br /> DRAW PLOT PL ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I r <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> JADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III, FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7. �0/7s_ <br /> ru 1 B9t o,;:. 1_/78 2M_ <br />