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_./ „ <br /> SAN JOAQUiN LOCAL HEALTH DI5TRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA '95205. Permit No. �T~ <br /> (209) 466-6781 § <br /> pp Telephone: Date Issued _�.-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (fomplete .In Triplicate) <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. 1862 and the Rules and Regulations -of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS S CITY/TOWN St.0QKf"�_ <br /> 4 <br /> Owner's Name T _.�. -Phone- - <br />�Address— ,I :..Ci.ty o oN <br /> Contractor's Name <br /> License f�j; = Phone <br /> IS CERTIFICATE OF'WORKMAN'S COMPENSATION INSURANCE. ON FILE- WITH-SJLHD? YES <br /> (TYPE OF WORK (Check) : NEW WELL K . DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION-0 WELL ABANDONMENT p OTHER( <br /> PUMP INSTALLATION ❑---SUMP-REPAIR[2-- RUMP REPLACEMENT❑ , <br /> DISTANCE TO NEAREST,: SEPTIC TANK f SEWER LINES '`—RIT- PRIVY_ <br /> SEWAGE DISP SAL FIELD CESSPTO'L/SEEPAGEPUBLIC D MEOTHERWELL �. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-- - <br />" INTENDED USE;'- TYPE OF:WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industrial.. Cable Tool Dia. of Well Excavation_ �r <br /> X -Domestic/private Dr.i I I ed <br /> Dome"stir/p`ublc Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea D <br /> Cathodic Protection �(T--Rotary Type of Grout <br /> Disposal Other `: Other Information <br /> Geophysical Surface Seal Instal ed. <br /> PUMP INSTALLATION:- Contractor <br /> Type of" .Pump _- H.P. <br /> PUMP REPLACEMENT: '[]State Work Done <br /> BUMP REPAIR: ❑State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater7a and roce ure <br /> I hereby certify that I have prepared this appl'i'cation and that the work will be done in accordant <br /> with_.:SAn,..Jo-aq.ua.n-Cou.ntyyQr-da,na.nc-es-S-- State-=l=aws , and Rules and Regulations of the San=Joaquin L-oca1, <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." � A.. --� ` <br /> I WILL CALL FOR A GROUT INSPECTION- PRIOR`TOG'ROUTING, AND, FINAL {INSPECTION. <br /> S'ZGNED TITLE: . DATE: <br /> - DR W 'PL T PLAff ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE. I _ <br /> ATPLICATION ACCEPTED BY .� � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE JI GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ZVI DATE El10 <br /> 98 <br /> FH 14 26 Rev. 9/ 8 14 <br />