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I <br /> iN JOAQUIN LOCAL .HLALIM U15tKiUt/ Permit No. <br /> FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 9505 <br /> Telephone: (204) 466-6781 ed <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> This Permit. Ex ires .I Year From Date Issued <br /> (Complete In Triplicate <br /> Application`is herebymade to the San Joaquin Local Health District for a permit to construct <br /> ad/or install the wrk herein described, This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the .Rules a.nd Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET- ADDRESS CITY/TOWN <br /> Phone <br /> Owner's Name ��., •' -{- <br /> Address -, u�, : ;r City <br /> Contractor's Name r %.� 1 i cense#: � � Phone — /f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'l INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLE] DEEPEN❑ RECONDITION ❑ DESTRUCTION( <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 c� <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 `D <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 /> Domdstic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: ContractorQ �& <br /> Type of Pump H• • <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done P �- <br /> DESTRUCTION OF WELL: Well DiameterG� Approximate Depth <br /> Describe Materia an rote ure <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 /> Health District. Dome 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 CALL FOR A CROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED L TITLE: DATE: <br /> DR W PL L N ON REVERSE SIDE <br /> FOR DEP TMEN USE ONL �s <br /> PHASE i G <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE�/3—.S_7 <br /> �'y 1 7 8 2M <br />