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SAN JOAQUIN,:LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: -= /1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit -No. <br /> _ .. Telephone: (209) 466-6781 <br /> Date Issued <br /> •i- APPLICATION FORQ <br /> �WELL CONSTRUCTION R PUMP PERMIT <br /> Thin Per mit Ex i res,,l Year ,F`rom Date Issued , <br /> Complete I,n 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 ,applicati'6n!.-is made -in compliance with San <br /> Joaquin County Ordinance,No. , 1862 and the Rules and Regulations of the .San Joaquin�Local Health <br /> District. <br /> EXACT STREET ADDRESS- Y/TOWN . <br /> a. <br /> Phone <br /> Owner's Name <br /> Address ��/� R City, <br /> License _____-- Phone, + - <br /> Contractor' s. Name <br /> IS CER7i F I CA7E OF ta0rs:t iAN'S"C 'iPENSATIO'N I EISUIZAN ON FILE WITH SJLHD? <br /> TYPE OF WORK (Check) : NEW WELLL RDEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP4.REPAIR❑ PUMP REPLACEMENT ❑{ <br /> DISTANCE TO NEAREST: SEPTIC TAN �SA� <br /> SEWER LINES, PIT PRIVYSEWAGE pISPiELp _ _C __.._ POOLI-SEEPAGE� I --- OTHER - <br /> , PROPERTY LINVQ-.fPRIVA -D ESTIC WELL 13S : PUBLIC DOMESTIC WELL �-- <br /> INTENDED USE TYPE OF WELL *'CONSTRUCTION SPECIFICATIONS <br /> Cable Tool-` Dia. of Well Excavation '► <br /> " Industrial <br /> Domestic/private Drilled Dia. of Well Casing <br /> --- -- Driven '" �" Gauge f FCasi ng P <br /> Domestic/public , <br /> Irrigation _Gravel Pack7 Depth of Grout Seal_, <br /> Cathodic Protection Rotary • .Type of-,Grout ,�t <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed byl <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> bescribe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan a <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 of California." <br /> I WILL FO A G UT IN C N TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: <br /> W PLOT PLAN ON REV E SIDE <br /> FOR D P RTMENT USE ONLY <br /> PHASE I DATE 2 �8 <br /> ! APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION °BY DATE <br /> /!4/7 <br />