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SAN JOAQUIN LOCAL- HEIALTH DISfRICI <br /> 'OFFICE USE: 1601 E. Hazelton: Ave. , Stockton, CA 95205 Permit No. <br /> Telephbne: (209) 466-6781 <br /> APPLICATIONJOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Th:i;s Permit Ex ires :1 Year From pate 'Issued <br /> Complete In Triplicate <br /> F S <br /> Application is hereby made to the 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 /> Joaquin County .Ordinance No. 1062 and the Rules and Regulations of the- San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS _ <br /> CITY/TOWN c <br /> Owner's Name Phone ! <br /> Address City <br /> Contractor' s Name ( Licensee_ Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATTO`3 IJlSURAPJ E ON FILE WITHSJLHD? YES NO ; <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN;V RECONDITION ® DESTRUCTION❑ � <br /> WELL CHLORINATION Q WELL ABANDONMENT ED OTHER 0 , <br /> PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENTQ ' <br /> DISTANCE TO NEAREST: SEPTIC TANKQ SEWER LINES PIT PRIVY <br /> SEWAGE� DISPSO AL FIELD,522 /f CESSPOOL/SEEPAGE PIT OTHER --- �' <br /> PROPERTY LIN &±RIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Y Cable Tool Dia. of Wel 1 Excavation <br /> _Domestic/private Drilled Dia. of Well Casin y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of GroutSeal '�. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ,�,sA4.0 A 1001141 <br /> Geophysical Surface rface Seal Inst <br /> a ed -by" <br />: PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP' REPLACEMENT: F] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter `s Approximate Depth <br /> Describe Material 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_thisrpermit 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 FORA G UT I E IO IOR TO GROUTING AND A FINAL INSPECTION.. <br /> SIGNS ,TITLE: A DATE:� 'k, �zp <br /> LyL�AW PLOT PLAN ON REVER IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { <br /> APPLI.CATJON ACCEPTED BY _ DATE <br /> [ ADDITIONAL COMMENTS: i- <br /> PHASE II GR UT INSPECTION "` ""PHASE' I.I;I- INAL INSPECTION.. _ <br /> iINSPECTION -BY DATE INSPECTION BY DATE 3 ' <br /> Vc'u�"thnc n.... ,o_77 1/76``, <br />