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° V SAN JOAQUIN LOCAL HEALTH DISTRICT �T <br /> fOR <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -// U ' <br />_ Telephone: . (209) 466.-6781XY 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> S-cam -3 <br /> This. Permit Expires 1 Year From Date .Issued i <br /> Complete In Triplicate 14 AI'L <br /> Ap¢lication 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 /> reanuinCounty Ordinance No. 1862 and the Rules and Regulations of the San Jjp quinOLoc 1 Health 3 <br /> istr�ct* /" <br /> EXACT STREET ADDRESS. I 0ox- S '�ar / rl TY TORN <br /> Owner' s Name 0l Phone� ��� _ <br /> Address Y2 2 City -- <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COSZSAT 0N INSURA"10E ON FILE WITH SJLHD? YES .VO <br /> TYPE OF WORK (Check) : NEW WELLE] DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR ❑ PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 01-HER <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br />—J1Irrigation Gravel Pack Depth of Grout Seal <br /> 7Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information �J <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 f <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_shal.l <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL OF A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED S D TITLE: DATE7 2-0-70P <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSP CTION <br /> INSPECTION BY DATE /f INSPECTION BY DATES Z 7F <br /> -45 <br />