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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -N-102L— <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date"Issued "7-(0- <br /> This Permit Expires 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 I <br /> Ooaquin County Ordinance No. 1862 and the RulesAnd Regula ions of the San -Joaquin Local- Health ' <br /> District. / <br /> EXACT ,STREET ADDRESS ® (� , CITY/TOWN ` <br /> Owner's Name Phone <br /> Address City. <br /> Contractor's Name, y "` -Licens.e# l Phone Q <br /> IS CERTIFICATE OF WORKMAN'S COMPENSA 0"! I aSURANCE ON` FILE WITH SJLHD? YE iV0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ � RECONDITION ❑ . _DESTRUCTI.O.N_❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP1INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial t Cable Tool Dia. of Well. Excavation <br />��M' estic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven " t, Gauge of Casing <br /> Irrigation Gravel Pack Depth' of Grout Seal <br /> Cathodic Protection �etaey Type of Grout <br /> Disposal - Other Other Information _ <br /> Geophysical„' . Surface Seal 'Installed by: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P,;t <br /> PUMP REPLACEMENT: + ❑State Work Done t <br /> PUMP REPAIR: i ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> U Describe Material and Procedure <br /> I hereby certify. that Ch' ave 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' f-.the work for which =this permit is issued, I shall <br /> not employ any person in such manner as, to become sct to Workman 's Compensation <br /> laws of California.”, <br /> I WILL CALL JFO -A GROUT INSPC N _PRIOR TO GROUTING__ ND A FINAL IN ON. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT L N ON REVE SIDE , <br /> PHASE I <br /> FOR DEPARTMENT U ONLY <br /> ��-.,,_ -�-- - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRPWI INSPECTION - PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE -k:?-z­'. ;i <br /> , . INSPECTION BY DAT�r zSt:+f <br />