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S T+c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Yo. <br /> Telephone: ( 66-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT _5-7 <br /> - . <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health: Distri=ct for a permit to construct <br /> and/or install the .work .herein described. This application is'made - in compliance 'w'ith San { <br /> Joaquin County:Drdinance Nof 1862 and the Rules and*'Regulations 'ofathe San Joaquin• Local Health <br /> District. <br /> 5 EXACT• STREET'ADDRESS ..- <br /> a Y/T / <br /> . . CIT OWN S����rFori! <br /> Owner's Name Phone <br /> .Address - � <br /> __., City,-, <br /> Contractor's Name <br /> ate. License# 7,702.-.Phone <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATION INSURA"SCE ON FILE WITH SJLHD? YES 0 <br />'. TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q. DESTRUCTION rl <br /> WELL CHLORINATION 0 WELL ABANDONMENT-0 - OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR C7'-- RUMP REPLACEMENT [] -C <br /> T <br /> DISTANCE TO NEAREST: SEPTIC TANK OS- <br /> SEWER LINES PIT PRIVY - C <br /> s` <br /> SEWAGE DISP_05AL__w.IELD CES—SP--OO-L/-SEEPAGE-FI-T---. =--OTHER::!:e=- <br /> r PROPERTY irhiro;_ PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WE <br /> LE <br /> INTENDED USE TYPE OF-WELL.., <br /> � Industrta4 CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation 2?5 <br /> �- _Domestic/privateS;{ Drilled Dia. of Well Casing . <br /> „ Domestic/public Driven Gauge of Casing <br /> _�I.rri gation - =X Gravel- Pack Depth of Grout 5ea r/ <br /> Cathodic Protection <br /> "` `. -�._Rotar y � Type of Grout-- ,��} <br /> Disposal Other ` Other Info.rmati ��"' <br /> _.__, Geophysicai f = <br /> } P Surface-Seal Installed <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ` R t N. . <br /> State Work Done �* <br /> PUMP REPAIR: _ ©State Work Done , f' •� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure `�Z` App-roxtmate Depth ' <br /> b4: <br /> I hereby certify. that I have prepared this application and that the work will be done ins <br /> with San Joaquin County Ordinances., State_Laws-,-rand-Rul-es-�a�nd'-Regulations of"�tt�e�"san'JoaqufLocale`; <br /> Health District. Home owner or ]icensed agent's signature certifies the following: <br /> "I certify. that in the per of the work for which this permit is issued, I shall ' <br /> not employ any person in uch 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 /> SIGNED TITLE: - <br /> D W P T L ON REVERSE .SIDE DATE:_, <br /> R DEP RTMEN USE ONLY <br /> PHASE I <br /> P�UTTION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE - -� <br /> PHASE II GROUT INSPECTIONS <br /> DATE �_�o_`?� PHASE IIT FINAL ' INSPECTION <br /> iNSP£CTION BY <br /> INSPECTION BY <br /> EH 14 `26 Rev. 78. DATE -2s-`1� <br />