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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 Permit No. 753'-/19� <br /> Telephone: (209) 466-6781 Date Issuedy-/-?S, k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From -Date Issued <br /> Comp ete 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 applicationfis made in compliance with San <br /> Joaquin County Ordinance No. 1'862 and the Rules and-Regulations of the San. Joaquin Local Health <br /> 'District. <br /> ( _ �tlow a�✓t' TY TOWN <br /> EXACT STREET ADDRESS ��s 2L / �N /��� Loc° l <br /> Owner's Name Phone - <br /> N <br /> City <br /> Address 0 / <br /> Contractor' s Name (`4���,��c ��'-��, �License# `�G Phone `/ ,�� <br /> IS CERTIFICATE OF WORKMAN'S S C6M1PENSAT(i/01: INSURA?ICE ON FILE WITH SJLHD? YES �l0 <br /> TYPE OF WORK' (Check) : NEW WELL❑ DEEPEN Q RECONDITION, DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION E7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC� AL FTANK SEWER LINES PIT PRIVY <br /> SEWAGE, DISPOSIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DORESTIC WELL PUBLIC DWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Wel 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 b <br /> PUMP INSTALLATION: Contractor H <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and Procedure <br /> I hereby certify that I .have,prepared this application and that the work will be done in accordant( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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." I <br /> I WILL CALL F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 44 , <br /> R PL L ON REVERSE IDE <br /> F DEP TMEN USE NLY <br /> PHASE I DATE / <br /> APPLICATION ACCEPTED BY '� � <br /> ADDITIONAL COMMENTS: ASE III FI4.L <br /> NAL INS T <br /> PHASE II GROUT 'INSPECTIONINSPECTION Y DATE INSPECT7�P <br /> BY —1 Z"� `" w •� - 7 M <br />