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V SAN JOAQUIN LOCAL HEALTH U15TKIC1 .f <br /> FFIC-FORE USE: 1601 E. Hazelton �5tockton, CA 95205 Permit No. i <br /> Telephone: (209) 466--6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT i <br /> This Permit Expires -1 Year From Date Issued <br /> Complete' In Triplicate <br /> Application is hereby made to the 'San Joaquin local Health District fora- permit to construct � <br /> and/or install the work herein described. This application. is made in compliance with San f <br /> Joaquin County Ordinance No. ' 1862 and the Rules and Regulations of the .San Joaquin Local Health � <br /> District. _. <br /> S dC <br /> EXACT STREET ADDRESS C1,5 0 - W, S �J CC CITY/TOWN C� "- _ s <br /> Owner's Name Phone <br /> Address _ City <br /> �c� ci <br /> Contractor's Name <br /> License# Phone <br /> IS CERTIFICATE OF WORKMAN`S COMPENSATION I�dSURAINCE Ott FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL E3 DEEPEN ❑ RECONDITION..Q 'DESTRUCTION E2 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q" OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK qO SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD g7a CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (b <br /> Industrial Cable Tool Dia. of Well Excavatiop 1'i- <br /> - - Domestic/private �-Drilled Dia. of Well Casing <br /> Domestic/publii c Driven Gauge of Casing pUc sck. -kt,0 i <br /> Irrigation X Gravel Pack Depth of Grout Seal s p <br /> Cathodic Protection x Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical ! Surface Seal Installed by. dur �- <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 <br /> y . <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." I 'A I <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />' SIGNED TITLE: _ DATE. "7 <br />' <3 kDRAW PLOT PL N ON REVERS SIDE <br /> FOR D PART ENT USE ONLY <br />. PHASE I <br /> APPLICATION ACCEPTED BY DATE__6// <br />' ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE r-3 7 INSPECTION BY DATE <br /> EFH 1a2F Rav" 12-77 "2M <br />