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M SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 9520_5 Permit No. / <br /> A Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expire.s 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 /> .'oaqu;n County Ordinance r4o. `1862 and. t'he . Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> � <br /> CITY/TOWN 6;4. <br />' EXACT STREET ADDRESS � k^�� � /044 r107t /s � • <br /> Owner's Name <br /> Phone <br /> r Address::. city n. <br /> Contractor's Mame License#/9321f—Phone t <br /> IS CERTIFICATE OF WORKMAN'S COMPErIS I0"�TtISURA*•ICE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTIONEJ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR® PUMP REPLACEMENT � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1- <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 �1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> C Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ilf -Surface Seal Ins-tall-ed by: <br /> FPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> .PUMP REPAIR: ®State Work Done U) c _ �- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 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 FOR A GROUT INSP.EC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> r SIGNS TITLE: �r� t f , DATE: <br /> R LOT PL ON REVERSE SIDE <br /> . ,_ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � � 7 <br /> ADDITIONAL COMMENTS: e57 (7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECT.ON;BY-_. - ��- .. DATE - w __ INS.PECTION BY_" :.DATE- Yom: <br /> - __ - _ - <br />