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Ice �� ///"?AN JOAQUIN LOCAL HEALTH DISTRICT FOR z <br /> OFF-ICE USE: 1601 E. Hazelton Ave.. , Stockton, CA 95205 Permit No. �-q� <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex fres 1 Year. Fram Date Issued <br /> Complete -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 CITY/TOWN <br /> Owner' s Name Phone 1 <br /> City <br /> Address <br /> Contractor' s Name <br /> �� — License# 23 Phone <br /> TS CERTIFICATE OF WORKMAN'S COIAPENSATIO'N 111SURAINCE (ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN [J RECONDITION ❑ DESTRUCTION Q <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR& PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT =ME <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLI <br /> INTENDED USE -�`TY,PE OF WELL CONSTRUCTISIndustrial Cable Tool Dia. of Wel.l._Excava <br /> Domestic/private Drilled , Dia. of Well Casing <br /> Domestic/public Driven i Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> j Geophysical F Surface Seal Installed b : <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ?� <br /> s, PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: E State Work Done ` <br /> :' rMT �D pth <br /> DESTRUCTION OF WELL: Well Diameter pp <br /> Describe Materia an , Proce ure <br /> I hereby certify that Ihave_prepared_ th-is application and that the work will be done in accordant+ <br /> } with"Sin Joaquin County Ordinances , State f.aws, 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." <br /> ! I WILL CALL F A OUT I PECTION RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r. ! TITLE: DATE: ~� <br /> r iNw r .fR W PLOT ,—PLAN ON REVERSE IDE <br /> aFOR DEPARTMENT USE ONLY <br /> k <br /> PHASE I <br /> �' ' DATE Z�',- � _ i,-x f <br /> APPLICATION ACCEPTED, BY � <br /> ADDITIONAL COMMENTS,:' -u `� PHASE III FINAL INSPECTION <br /> PHASE •I'3 7GRO NSPE TION <br /> INSPECTION' BY ' DA7E; 'f INSPECTION BY DATE Z ' <br /> 1 9 .77 1178 2M . <br />