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SAN JUAQIUIN LULAL HtAL I H U1�.I KI I <br /> FFICE USE: 1641 E. Hazelton- Aver: , Stockton, CA 95205 Permit No., <br /> Telephone_: (209) 466-6782 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT /_� <br /> This `Permit Ex.- ices 1. Year From Date' Issued <br /> Complete I.n Triplicate <br /> Application is hereby made to the San Joaquin Local- 'Health ,District for a permit toyconstruct .: <br /> and/or install the work herein described. . .This application is made. in compliance with San - <br /> ,'oaquin County Ordinance No. 1862 .and the Rules and Regulations of the. San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSCITY/TOWN /Aara <br /> Phone <br /> Owner's Name f/ n Cf 165 <br /> Address City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"PENSATION INSURAINCE ON FILE WITH SJLHD? YES 1140 <br /> TYPE OF WORK (Check): ,NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION, PUMP REPAIR 0 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 /> Domestic/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 i r-e- <br /> Type of Pump H.P. <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 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State` Laws , and Rules and Regulations of the San Joaquin Local <br /> F 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 CALIg UR A GROUT INSPECTION RRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: Z/— <br /> (DRAW <br /> /—DR W PLOT PLFN ON- REVERSE SIDE <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I r �, DATE <br /> I APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE MI FINAL IN5PECTION <br /> ' .INSPECTION BY DATE INSPECTION BYTE <br /> rL) R A 11 R_.. 1 n ,7 ... _ 1 179 2M <br />