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/ t <br /> (,// SAN JOAQUIN LOCAL HEALTH DISTRICT <br />--FQR_QFF^ICE USE: 1601 E. Hazelton Ave, , -Stockton; �-GA 95205 Permit No. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - <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 4 <br /> and/or install the work! hereirildescribed. This application is made in compliance with -San <br />�_Ioaauin County Ordinance No.- 1862 and- th Rules and Regulations of the San Joaquin Local Health r <br /> EDistric <br /> EXACT STREET ADDRESS 1' - app - CITY/TOWN <br /> Owner' s "Name Phone' �Fzy -%5- -- } <br /> Address / Cit .� . <br /> Contracto'r's Name F License#,2 Phone ��f / <br /> IS CERTIFICATEOF WORKMAN'S COMPENSATION INSURA"NCE ON FILE WITH SJLHD? YES NO <br /> ANO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK +moi ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD A51+ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF TELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <br />___K_Domestic/private Drilled Dia. of Well Casing 1. 7' <br /> Dbm_ estic/publ ic— `T - °Drtveri Gauge -of--Casing - _ ,_ 4�. <br /> Irrigation _ --X_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Inv,tal e b <br /> PUMP INSTALLATION: Contractor <br /> Type ofIPump — N.P. k <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done w <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r� <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. " t <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 'TITLE : DATE: <br /> (DRAW PLOT N ON REVERSE SIDE <br /> i <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /,2 2 7� <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION t PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 2 <br /> 2 � r3 I'N PECTION 13Y o DATES 2( 7 <br /> b <br /> � .,,�;,, P"�, are <br />__H 1 a9A, Rnll Q?_77 ib � 0 " 1 1 2M <br />