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x ✓ SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zy, 7 7g <br /> - <br /> APPLICATION <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued Z�_ <br /> This Permit Exoires 1 Year From Date Issu'ed ' <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 '�LO!� 9S S� e erV CITY/TOWN r_ <br /> Owner's Name °� Phone <br /> Address----,- City `rr <br /> Contractor' s Name o _ License# Phone 'Z�—} � _ <br /> IS CERTIFICATE OF WORKMAN'S . CO!1PENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES 1140 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT <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 /> omestic/private Drilled Dia, of Well Casing <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 Surface Seal Installed by:_ <br /> PUMP INSTALLATION: Contractor A, S <br /> Type of Pump St,jt _ .- H.P. �S <br /> PUMP, REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR• ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify .that I have 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 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t TITLE: DATE: / <br /> R W PLOT PLAN ON REV SE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �,' DATE .� #'� <br />' ADDITIONAL COMMENTS: `� `�— <br /> PHASE II GROUT INS ECTION PHAS III FIN INSPECTION <br />',INSPECTION BY DATE INSPECTION 8 DAT .-� '�� <br />