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, . T, ,: ...... ., <br /> 'TN LOCAL HEALTH DISTRICT <br /> FOVQFFICE USE: 1601 E. h n Zf <br /> Ave. , Stockton, CA 95205 Permit No. I/1 <br /> elephone: (209) 466-6781 pate Issued a ?_7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From pate Issued <br /> Complete In Trip i tate <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 /> N CITY/TOWN <br /> EXACT STREET ADDRESS 16 CIDJ <br /> Phone <br /> Owner' s Name - <br /> Ci tyr z� <br /> Address � <br /> Contractor' s Name - <br /> Li cense# Phone <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATIOM IiISURAINCE ON FILE WITH SJLHD? YE5 �� 530 <br /> TYPE, OF WORK (Check) : NEW WELL',' DEEPEN ❑ WELRECONDITION NMENT CI DESTHERT�N� <br /> WELL CHLORINATION 0 <br /> PUMP INSTALLATION �Z" PUMP REPAIR❑ PUMP REPLACEMENT L� <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ►�mestic/private Drilled Dia. of Well Casing �r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical A <br /> Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor H P. <br /> Type of Pump <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP,' REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> withSan Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 R A ROUTIN ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT- PETN ON RE ERSE E <br /> F R DEPART ENT USE ONLY <br /> PHASE I DAT -- --J <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II NAL INSPECTION <br /> GROUT INSPECTION PHASE III FI <br /> INSPECTION BY DATE INSPECTION BY DATE- --;?7 <br />