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SAN JOAQUIN LOCAL HEAL1H UISIKIUI <br /> FOR OFFICE USE: 1// 160;x. Hazelton Ave. , Stockton, CA 1205 Permit No.�� <br /> Telephone: (209) 466-6781 -1' <br /> --1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 for a permit to construct <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 /> Cistrict. �3 '� �,...�'` S7 /Ak�i—'e-1 <br /> EXACT STREET ADDRESS .S'D /cKc i4—r ( ,N,� �c.'�L r E(7�,p,1Q� c �- ! -= CITY/TOWIN LSC <br /> Owner' s Name C �— Phone �j F <br /> S <br /> Address ('. i} & J , Z 4- city /- +f C <br /> Contractor' s Name 'T, S c,,, Li cense#. Phone ->�` <br /> 'S CERTTFICATE OF WORKMAN'S CO"PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ G <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 1---1 <br /> PUMP INSTALLATION ❑ PUMP REPAIRED PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: UIState Work Done f?L/1..� I t� <br /> 4 SLS 'ti•L Tart � �n 11nLrn<< <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 accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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." <br /> I WILL CALL F R A GROUT IV.SPECTION PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE: TE: -7 <br /> DR W PLY PLTN ON REVER E SIDE) r= <br /> FOR DEPARTMENT USE ON 4� - <br /> PHASE I GATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONt 01HASE III INAL INSPECTION <br /> INSPECTION BY DATE�(/� Ids CTION BY DATE ` / f <br />