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F JOAQUIN LOCAL HEALTH UISIRICI <br /> Telephone: Permit No. <br /> OFFICE USE: �' 1601 � AVe. , Stockton, <br /> n781A�5 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San <br /> aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. <br /> ACT STREET ADDRESS X4-q6-1 N SOIA/L-ES Phone <br /> l�� TOWN <br /> ner's Name h T ' P K ' S 7- Phone <br /> dress a4g51 til, Sn a/L 5 �D City f1C/Sf/ r <br /> ntractor's Name C Sc�r /r�� T%/_ ,_i itii<i— License#? ?'Cc`'I-Phone_7� <br /> iR <br /> CERTIFICATE Cc WOPKMAN'S ='TENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> PE OF WORK (Check) : NEW WELL n DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ 9 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> STANCE TO NEAREST: SEPTIC T,ANK� SEWER LINES SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE,25-PRIVATE DOMESTIC WELL --_ PUBLIC DOMESTIC WELL `-- c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y C <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Sea S/ <br /> Cathodic Protection Rotary Type of Grout 9 5 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> IMP INSTALLATION: Contractor <br /> Type of Pump- <br /> IMP <br /> IMP REPLACEMENT: ❑State Work Done <br /> IMP REPAIR: ❑State Work Done <br /> :STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an roce ure <br /> hereby certify that I have prepared this application and that the work will be done in accordancf <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> �alth District. Home owner or licensed agent' s signature certifies the following: i <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 /> WILL CAL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: DATE: <br /> IDRVW PLOT L N ON REVERSE <br /> y SIDE <br /> FOR DEPARTMENT USE 0NLY <br /> 4ASE I �j DATE <br /> ?PLICATION ACCEPTED BY <br /> 301TIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> ISPECTION BY DATE INSPECTION BY ? DATET_ <br /> �7 � �� 1/78 2M <br />