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SAN JOAQUIN LOCAL HEALTH DISTRICT, C-/f,"Fog Permit No. -4 <br /> OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued - 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate t <br /> Application is hereby made tolthe 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 /> i .'oanuin County Ordinance 1tio. �1862 and the Rules and Regulations of the San Joaquin -Local. Health <br /> District. <br /> EXACT STREET .ADDRESS g �� IZ CITY/TOWN -1 � <br /> � " �" � 4 Z� Phone <br /> Owner' s Name v ,��ro tR <br /> Address f / City ✓ d <br /> Contractor's Name S`�M'' — License# Phone <br /> I5 CERTIFICATE OF WORKMAN'SCOiPENSATIO"I INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ V <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ cQ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBL C DOMESTIC WELL <br /> INTENDED USE ` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of Well Excavation <br /> r w DAmesticJ--private _ _ Drilled , Dia. of Well Casing - _ - - <br /> - Domestic/publ i c _ f� Drive i "'�'" Oauge f C i rag-- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> f <br /> eophysical Surface Seal Installed b <br /> G <br /> 1PUMP INSTALLATION: Contractor H.P. <br /> Type'of Pump <br /> PUMP REPLACEMENT: Q State Work one <br /> PUMP REPAIR: ❑State Work Done <br /> 3 � <br /> Well .Diameter 6 Approximate Depth / <br /> Descr..ibe Material and Proce ure <br /> Y � <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> rHealth 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 /> N DATE: <br /> ISIG E TITLE: <br /> DRAW PLUI PLAN ON REVEREIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I DATE �,�7-- 4 <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> _ / DATE X <br /> ,INSPECTION BY DATE !+� INSPECTION BY <br />