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SAN JOAQUIN LOCAL HEAL1H UI5IKILI <br /> FFICE USE: Y 1601 E. Hazelton -Ave. ;-Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 � <br /> 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 /> drnd/or install the work herein described. This application is made in compliance with San <br /> ,1.oaquin County Ordinance No. 1862 and the Rules and Regulations of the: San Joaquin .Local .- Health <br /> District. [Do'Zr]S <br /> EXACT' STREET ADDRESS CITY/TOWN <br /> Owner's Name 1A Phone bokr_ _ <br /> Addressej City 99a <br /> Contractor' s Name icense4,2 LJ- Phone - <br /> TS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURAINCE 'ONFILE WITH SJLHD? YES <br />-TY-PE OF-WORK (C—heck—) NEW-'vJ£L-L-ice-G£EPEN•Cl - RECONDITION-Q - ----DEST-RUCTION M- _----- --- - --- , <br /> WELL CHLORINATION d WELL ABANDONMENT 0 OTHER 0 z <br /> PUMP INSTALLATION �g PUMP REPAIR❑ PUMP, REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKna SEWER LINESab /Lf PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC; DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION'�SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation q <br /> Domestic/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 Instal ed b ° <br /> PUMP INSTALLATION: Contractor. ArV ' <br /> Type of Pump H.P. �- <br /> PUMP REPLACEMENT: C7 State Work Done <br /> PUMP REPAIR: ❑State Work Done LL <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 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=of­Cali-fornia." - <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION.- <br /> SIGNED TITLE: DATE: /1/_lba _ <br /> �DRAW PLOT PON ON REVERSE SIDE <br /> : A FO --'DEP iRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE " / 7 ? <br /> ADDITIONAL COMMENTS: 0 <br /> PHASE II GROUT-INSPECTION-. <: PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Cu ,Ane -7'7 1 /7A 2M <br />