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SAN JOAQUIN LOcW.,,HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,'. Stockton, CA 95205 Permit No. o <br /> Telephone (20 9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -�5�� <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's,canstruct <br /> and/or install the work herein described. This application is made in compl;i:a.ncew�t1"' San <br /> oan.:in County Ordinance 1o. 1.862 and the Rules and Regulations of the San Joaquin Local.- Health <br /> u,istr�ct. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phone , <br /> Address &� <br /> t C'ty <br /> Contractor's Name /yI� _ _ _C_ �f� r License �F �, hone ! <br /> 01 <br /> IS CERTIFICATE OF WORKMAN'S 'COMPENSATIOIN I1114SURANCE ON FILE WITH SJLHD? YES .�} NQ <br /> J <br /> TYPE OF-WORK (Check) : NEW-�WELL14-_.,- DEEPEN ❑' "RECONDITION ® DESTRUCTION[] <br /> ` . a WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 '4 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ � + <br /> DISTANCE TO NEAREST: SEPTIC TANK"j9 LINES' ... 4 .PIT PRIVY �. <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -. PRIVATE.DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _.,IA-Cable Tool Dia. of Well Excavation �7f! <br /> Domestic/private Drilled Dia. of Well Casing_ W' n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _A_jLRotary Type of Grout j <br /> Disposal Other Other Information - { <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor j <br /> Type of Pump H.P. <br /> PUMP-..REPLACEMENT: p State Work Done <br /> PUMP ,REPA.IR: Q State Work Done <br /> DESTRUCTION OF WELL: ; Wel T. Diameter Approximate Depth <br /> Describe Mate-r-57—and Procedure <br /> I hereby certify that I have prepared this app`1-ication 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: ax <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> t <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR D PARTMERT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY BATE a 7 <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY T A DATE 7r, <br />