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SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltob Ave. , Stockton, CA 95205 Permit NO-72-9- 60 <br /> Telephone: (209). 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit ,Ex ires 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 <br /> and/or install the work herein described. This application is made in compliance with San <br /> Ioapuin County L'rdinance No. 1862 and the Rules and Regulations of the San Joaquin Local..Health <br /> District. <br /> CITY/TOWN j <br /> EXACT STREET ADDRESS Ph <br /> Owner' s Name <br /> Address— .-- ) 'X City <br /> Contractor's Name License# Phone - <br /> IS CERTIFICATE OF -WORKtIAt4'S_ COt.IPENSATIO"I__lt4SURA"•ICE ON FILE WITH SJLHD? YES NO - <br /> YTYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> RI [] <br /> WELL CHL ATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> tDISTANCE TO NEAREST: SEPTIC TANK 02 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL fOPRIVATE DOMESTICPWOELLn�EPUBLIC DOME TICOTHERW LL <br /> PROPERTY LINE�'d�. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -_ <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing ( e - <br /> Irrigation Gravel Pack Depth .of Grout Seal u <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : /d- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y H.P)( <br /> PUMP REPLACEMENT: []State Work Done <br /> ` PUMP REPAIR: ❑State Work Done -- - <br /> ._,_..._.. mate roxi Depth <br /> DESTRUCTION OF WELL: Well Diameter Approximate p <br /> Des ibe M terial and Proce u r e <br /> f.3 <br /> I hereby certify that I have prepared this application and thatttletor7kwill be done in accordanc <br /> 1with 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: " <br /> I WILL CALL FORA ROUT INSPECTION PRIOR TO GROUTING A A FINAL INSPECTION. <br /> ISIGN 0.1 TITLE: . <br /> � DATE: <br /> DR PLOT PL N ON REVER E SI E <br /> W <br /> OR EPAR - ENT USE ONLY <br /> PHASE I DATE, zZ <br /> APPLICATION ACCEPTED S <br /> iADDITIONAL <br /> COMMENTS: <br /> ° PHASE II GROUT INSPECTION PHA E III FINAL INSPECTION <br /> 1INSPECTION BY 943" DATE I INSPECTION BY C DATE <br /> ` _ m 117.8• 2M. <br />