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SAN JOAQUI�J{_OCAL HEALTH DISTRICT Permit No. <br /> r <br /> FFICE USE: 1601 E. Hazelton A`ve. , �S'tockton, CA 9520 <br /> Telephone:- . (209.)* 4664781 Date Issued - -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires .l "Year. From Date. Issued <br /> Complete In Triplicate <br /> Aoplication 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 /> No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ,'oaquin County Ordinance _ <br /> j Cistrict. f <br /> E CITY/TOWN,J4, <br /> EXACT. STREET ADDRESS � � ° Gc.) <br /> - Phone <br /> Owner's NameCity <br /> Address. .� 8I / Phone�.3=i <br /> Contractor' s Name License l 0 � <br /> '.S CERTi iC <br /> ATL 0 WORKMAN'S CO"}PENSATION I1111SURAINCE ON FILE WITH SJLHD? YES �y0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ ,,,,RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION P, PUMP REPAIR❑ PUMP REPLACEMENT ❑ �, <br /> - O <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <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 Cable Tool Dia. of Well Excavation <br /> Dia. of Well -Ca•sirgc * . <br /> Domestic/private Drilled _ �. <br /> ` Domestic/public � Driven Gauge of�Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <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 <br /> PUMP REPLACEMENT: ❑State,Wor-k'= one <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate-Depth <br /> Descr'a�be Materia and Procedure <br /> I hereby certi fy that I have 4 prepared-Ati i:"s..,;.appl.i cati on and that the work will be done in accordar <br /> with San Joaquin County Ordinances,�State Laws; and Rules and Regulations of the San Joaquin Loca <br /> d agent' s signature certifies the following: <br /> Health District. Home-owner or license <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 /> tlaws of California." '- <br /> I WILL C ROUT INSPECTION PRIOR TO_GROUTING MND-.A, FINAL INSPECTION. <br /> ­TITLE: '*.. DATE:- --/- A - — <br /> SIGNED DR W PLT L N ON"REVERSE SIDE <br /> FOR DEPARTM NT USE 'ONLY <br /> PHASE I DAT <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS; PHA E III--FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE - INSPECTION B DATE. <br /> 21 <br />