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'xy <br /> r SAia _JOAQUIN LOCAL HEAL1H UISIKIUI <br /> EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�1q�iI <br /> Telephone: (209) 466-67.81 <br /> ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6- -? <br /> This Permit Ex fres 1Year From Date Issued <br /> Complete In ..Tri pl i cane <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 /> I-oaquin County Ordinance No. ` 1862 and the Rules and Regulations .of the San Joaquin Local Health <br /> District. ,4T-37 <br /> 02 <br /> EXACT STREET ADDRES v�?4P_ LCJ' CITY/TOWN <br /> Owner's Name Phone <br /> r <br /> Address City <br /> Contractor' s Name License#3y J�yp a Phone C <br /> IS CERTTrTCATE 0 WORKMAN'S COMIPENSATIO"I INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ � <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ;Domestic/private Drilled Dia, of Well Casing ; <br /> Domestic/publ.i,c Driven Gauge of Casings ' <br /> Irrigation ,° � }�---- - ---Grave1_-P-ac-k- -------,—_Depth• of- Grout- Seal- 4 { <br /> Cathodic Protection Rotary Type of Grout _ - f <br /> Disposal Other i Other Information <br /> Geophysical., Surface Seal Instal ed by: <br /> PUMP INSTALLATION:, i Contractor <br /> ' Type of Pump '1��- - - H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> F PUMP REPAIR: _ ❑State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> `• � "Approximate-Depth <br /> Describe Material and Procedure f <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San 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 ',Yor 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 A GROUT INSPECTION 'PRIOR TO GROUTINGiAND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �Z <br /> (DRAW PLOT PL N ON.,REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> ( APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. . PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 9426' RPU_ 12-773 1 /78 2M <br />