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SAN JOAQUIN LOCAL HEALTH DISTRICTFOk-OPermit No. <br /> FFICE 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 /> Thi-s Permit. Expires 1 Year. From Date Issued <br /> Complete In .T.ri pl i cats . <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to con���uct <br /> and/or install the work hereih� described. This .appl,ication is made -in compliance with <br /> oaquin County Ordinance No. 21862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN_ S�.CI�r c� <br /> Phone <br /> Owner' s Name <br /> Ci ty. . <br /> Address <br /> Contractor' s Name , � ` d�✓ Licensed Phone a , <br /> 'S C£RTirICATE OF 1JORKriAtd'S C&MPENSATION I'1SUfiA"ICE ON FILE WITFI SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN C1 RECONDITION C3 DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT Ej OTHER ❑ <br /> PUMP iNSTALLATION -0 PUMP REPAIR❑ PUMP .REPLACEMENT gl;zL <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> PIT OTHER <br /> SEWAGEDISPOSAL FIELD CE—SS—POOL/SEEPAGE <br /> C WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTI <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 /> Domestic/publicDriven Gauge of Casing <br /> Irrigation '' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection `J j,• x Rotary Type of Grout - <br /> Disposal OtherOther Information <br /> Geophysical �{ Sui^face Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump " H.P. <br /> PUMP REPLACEMENT: State Work Done 'T Y. Al r !_L S <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxi:mate`Depth. <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work. will be done in accordant <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." i <br /> I WILL CALL FO GROUT SPEC ON PRIOR TO GROUTING AND A F AL INSPECTION. <br /> SIGNED "� TITLE: DATE: <br /> DR W PL T.4PL N ON REVE S SI E <br /> F R DE ARTME T ;,USE ONLY <br /> PHASE I } ,,,.` <br /> APPLICATION ACCEPTED BY . i1 DATE_4*— <br /> ADDITIONAL COMMENTS: lJ <br /> PHASE` II GROUT INSPECTION PHASE III INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES r7 <br /> r I , AAL n_... ,13 77 1 7 2M <br />