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SAN JOAQUIN LOCAL HEALTH DISTRICT --...�._._. <br /> EDE- OFFICE USE: -1b01 ,E. Hazelton Ave. , Stockton, CA 95205 Permit No: -r ! <br /> � . J Telephone: (209) 466-6781 w . a <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date: Issed `7-10- <br /> �® This Permit .Expires 1 Year From Date Issued ;, <br /> . � Complete In Trip icate G <br /> Application is hereby mfte%`& the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. Tn his application is made icompliance with San` <br /> Joaquin Coun 186 RulmWegulati ns of t S n Joaquin Local Health <br /> District. � , ' I <br /> EXACT STREET ADDRESS CITY/TOWN <br /> 1 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# Phone CZ110 3Z. <br /> IS CERTIFICATE OF WORKMAN'S COMPE ATION INSURAINCE ON FILE WITH SJLHD? YES NO V <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [J RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLONATION ❑ WELL ABANDONMENT ® OTHER:.,] �t <br /> PUMP INSTALLATION Cl PUMP REPAIR❑ PUMP REPLACEMENT C] d, <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 USETYPE OF WELL CONSTRUCTION SPECIFI T NS <br /> Industrial Cable Tool Dia./OfWell Excavation <br /> n <br /> Domestic/private Drilled DJ, of Well Cas1ng <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. ,/Depth of Grout Seal # <br /> Cathodic Protection =Rotary r ' Type of�Grout ! �. ! <br /> Disposal Othe'r�.� , OtherAInformation` , <br /> Geophysical ' Surface Seal Instal e by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpf; W.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState .Wor`k. Dome x - <br /> DESTRUCTION OF WELL: Well Diameter \{Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be 'done in-adcordance <br /> with San Joaquin County„Ordinances, 'State Laws, and Rules and Regulations' of the S.an-`;oaquin Local <br /> Health District. Home owner or licensed agent"s signature certifies the followi g: <br /> "I certify that in the performance of the work for which this permit is.-issued, I shall <br /> not ny person in such manner a`s to"become subject to Workman`.'s Compensation, <br /> 1 s of Cal 'fornia. " ” <br /> I WI L CALL FO GROUT INSPECTIO� ,RIOR TO GROUTING AND A FINAL JNSPECTION. <br /> SIGN '. TITLE: ' DATE: (; J <br /> f' DR W PLOT PL. N-ON REVERSE $JDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIO� BY HATE INSPECTION BY DATE q J-7 <br /> LI 1 A 7G' o.... ,n 17 <br />