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SAN JOAQUIN LOCAL HEALTH DISTRIC f <br /> QR FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - -22 <br /> i <br /> This Permit .Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br />_ pplication-is hereby made to the San Joaquin Local Health District fora permit to onstruct <br /> and/or. install the work herein described: This application is made in 'complianc th San <br /> YJ <br /> r �oaauin County Ordinance rIo.e1862 and. the Rules and Regulations of the San Joaq Local Health <br /> r iistrict. <br /> � r <br /> EXACT STREET ADDRESS .� S oZ CITY/ WN. <br /> Owner' s Name r Pho " <br /> Address . C9 C. <br /> y _1 �... <br /> Contractor's Name --'/' E ' {Licens hone�I <br /> IS--CCRTI`FICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD YES NO-- � ` + <br />' TYPE OF WORK (Check) : NEW WELL RR—DEEPEN ❑ RECONDITION ❑ D TRUCTION❑ 'I <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION C�PUMP REPAI ❑ P P REPLACEMENT [� � <br /> F , <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PI PRIVY <br /> SEWAGE� DISPOSAL FIELD CESWP EPAGE PIT OTHER 2' <br /> PROPERTY LINE/- PRIVATE DOMEST C PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrialv. , CableToo a. of Well Excavation <br /> E _Domestic/pri'vate Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing fy <br /> Irrigation Gravel Pa Depth of Grout Sea <br /> C Cathodic Protection ,`Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> �,• z <br />' PUMP INSTALLATION: Contrac r � <br /> .Type of ump-- - H.P. <br />, PUMP REPLACEMENT: -Q Stat Work one <br /> - <br /> PUMP REPAIRm: ..[] it Donees .: � ti. �'� ,; f <br />� DESTRUCTION' OF WELL: W A is ter ` �Rpproximate Depth <br /> De Vi Material and Procedure <br />' I hereby certify th `e prepared this application and that- the work will be done in accordance <br />' with San Joaquin C rdinances State- Laws and Rule°s` °and1aR8 ulataons of the "'San Joaquin Local <br /> Q Y a 9f � q <br />' Health Distri m owner or licensed agent's signature certifies the<folLlowi.ng: <br /> "I certif th the performance of the work for which this pe�rmitlis ss'uod,, I shall <br /> not emplo erson in such manner as to become, subject to :Workman 's Compensation <br /> laws of Ca rnia ' <br /> I` I WILL CALL F A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED '' <br /> TITLE : .._� I - DATE: <br />' (DRAWPLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASEI `''. <br /> APPLIC IONACCEPTED ,BY DATE <br /> ADDITIONAL COMMENTS: +" \ <br /> j!­�_PHASE IIwGROUT INSPECTION- _-.P.HASE III FINAL INSPECTION <br /> INSPECTION BY DATE; �'4, �. v 4 INSPECTION BY DATE <br /> Irw 1A7r- D. . 10 .77 1 1'7Q T.W <br />