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F + <br /> SAN JORQUIN LOCAL-HEALTH DISTRICT <br /> FlR_OF ICE USE. 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No.7� y <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ _> <br /> This Permit 'Ex ires-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 ,Jnstall" the work herein;described. This application is made in compliance with San <br /> I-Ioan;jin County Ordinance No. 1862 and the- Rules and Regulations. of the San "Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS a'1y` W CITY/TOWN [ , <br /> Owners Name , 4 � �, ,E- Phone <br /> Address <br /> Contractor's NamODA/ F. License� ,f"Phone ?G?-& <br /> IS CERTIFICATE OF .WORKMAN'S COP1 ENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION 0 � <br /> WELL CHLORINATION C3 WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ . PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 f Cable Tool Dia. of Well Excavation. <br /> _Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> . Irrigation A Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ii Rotary Type of Grout <br /> Disposal 11 Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �� V <br /> „ Type off Pump .Su6 ' 4�s°a <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP - R-: nState Work Done <br /> DESTRUCTION OF WELL: Well Diameter App oximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance' <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 IN EC ION IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED / TLE: r'0.1' DATE: , <br /> RAW PLOT PL ON "REVERSE SIDE ` <br /> FOR DE ART ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED: BY— DATE /r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I , AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / ? - <br /> EH 1426 RPv.. 17_77 <br /> ' 178_ .2M <br />