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-FF CE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued J3� <br /> ('Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District foraermit t <br /> and/or install the work herein described. This application is made in compliancewith nSanuct <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> 4/ d 2 Ro h -e er T–A <f6kR o !c. <br /> EXACT STREET ADDRESS 1 <br /> Owner's Name /1A '° gCITY/TOWN <br /> 5 <br /> Phone G <br /> Address 3 K35 /17�i <br /> Contractor's Name Ci <br /> a . ty �`'' . <br /> /+'cense ,2 Phone_ <br /> IS CERTIFICATE OF WORKMAN'S GOfSP NSATION INSURA"fCE ON FILE WITH S ? <br /> JLHD. YES A--- <br /> TYPE OF WORK (Check)-:, -NEW WELL IT— DEEPEN ❑ RECONDITION [ DESTRUCTION <br /> •'"' WELL CHLORINATION D . WELL ABANDONMENT Q OTHI-Rf� <br /> PUMP INSTALLATION ❑, PUMP REPAIR[2 RUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKPW SEWER LINES 5e 'I PIT PRIVY �? <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PI�`� OTHER 4 <br /> PROPERTY •LIN PRIVATE OMESTIC WELL t PUBLIC D MESTIC WEA` <br /> INTENDED USE TYPE OF.WELL., CONSTRUCTION SPECIFICATIONS w` <br /> Industria -C able Tool ia. -of Well Excavation <br /> Domestic/private Drilled �� <br /> Domestic/pub.lic �/ Dia. of Well Casing <br /> Irrigation - Driven Gauge of Casing �� <br /> �Grav lack Depth of Grout Sea r <br /> Cathodic Protection �o <br />_.__Disposal Otr Type of Grout �� <br /> Geophysical Other Information <br /> PUMP INSTALLATION: Co rac r Surface Sea] Instilled D wr <br /> Ty Pump <br /> PUMP REPLACEMENT: H.P. <br /> Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe MateVIdl and Procedure Approximate Depth <br />[ hereby certify that I have prepared this application and that- the work will be done in acc <br /> vith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San JoaquinoLocale <br /> iealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> IGNED TITLE• <br /> L L TI REV RS E _ DATE: <br /> HASE I R DEP RTMEN USE LY <br /> PPLICATION ACCEPTED BY �� s <br /> DDITIONAL COMMENTS: DATE ,2 <br /> PH SE GROUT INSPECTION <br /> ISPECTION BY DATE PHASE III 'FINAL INSPECTION <br /> 14 .26 Rev. – INSPECTION BY _ DATE <br /> ti <br /> __ Me .. u <br />