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II SAN JOAQUIN LOCAL.HEALTH DISTRICT permitOFQR FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 <br /> �i Telephone: {209) 466-5781 Date Issued 71' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> li This. Permit- Ex ires .I' Year from Date Issued <br /> 1 <br /> Complete In .Triplicate <br /> gpplica <br /> tion is hereby made to the San Joaquin Local Health District inr- a -p rmit0twith nSanuct , <br /> ianc <br /> and/or install the work herein described. This application 3s <br /> jin Count ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />,,oan Y <br /> District. (i. CITY/TOWN <br /> EXACT STREET ADDRESS <br /> Phone <br /> Owner' s Name ; <br /> .. � . City <br /> Address ityAddress <br /> r Li cense# 3- 7 r Phone^ - <br /> Con'tractor's Name r10 <br /> I5 CERTIFICATE OF WORK4iAf�'S CO�IPENSATig"I .I_NSURANry Ora FILE WITr1 SJLHD? YES i <br /> ;; DESTRUCTION[D <br /> TYPE OF WORK (Check) : NEW -,WELL 0 DEEPEN C� RECONDITION [] <br /> WELL• CHLORINATION WELL ABANDONMENT EP MP REPR EMENT : <br /> PUMP:.INSTALLATION PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A PIT PRIVY .�. <br /> TIT E <br /> SEWAGE DISPQSAL FIEVATE pOMESTS OSPOSP 4�LSEE PUBLIC DOME TICR7 L <br /> OT' <br />}: PROPERTY LINE PRI <br /> TYPE OF WELD CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE.`, ;i pia. of Well Excavation <br /> Industrial �:F:�: .._ � Cabl e Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/pr.ivate. Driven - Gauge of Casing <br /> Domestic/pub,lic Depth of Grout Seal <br /> Irrigation �� Grayel Pack De P <br /> Te of Grout <br /> Cathodic Protection Rotary Other Information <br /> DisposalOther <br /> _ Surface Seal Instal ed <br /> Geophysical <br /> �l <br /> PUMP INSTALLATION: Contractor H.p, iiz <br /> Type of Pump <br /> PUMP REPLACEMENT: ;p State Work Done e� <br /> kPUMP REPAIR: ! Q State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify b certif that I have prepared this application and that the work will be done in accordant <br /> Mwith• San Joaquin County Ordinances , State Laws and Rules and Regulations of the San Joaquin Local <br /> Health District. Homei-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 /> er as to become subject to Workman's Compensation <br /> not employ any person in such mann <br /> ► laws of Californiail" <br /> , IF WILL CAL R GR UT IN <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ,,r, TITLE: DATE: �- <br /> SIG:NEDDR W PLOT PL N ON REVERSE SIDE <br /> , FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY '� DATE INSPECTION BY <br /> ^} 7B. 2M <br />