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SAN JOAQUIN LOCAL HtALIH UiJIKIUI <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ��- <br /> Telephone: (209) 466-67'81. Date Issued/- d-7 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT.• <br /> This Permit Ex ires 1 Year From Date Issued <br /> I <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> arid/or install the work herein described. This application is made in compliance with San <br /> , oaquin County Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin Local_ Health <br /> District. <br /> EXACT STREET ADDRESS S' CITYJTOWN <br /> Owner's Name <br /> Phone .3 C�?- <br /> City <br /> Address a _ <br /> Contractor's Name L Li cense#3_I-'og` Phone 3 IS CERTI-F"I-C-ATE-OF WORKMAN'S COMPENSATION I1,11SLRANCE ON FILE WITH SJLHD? " YES - - <br /> .0 <br /> TYPE OF WORK (Check) : NEW WELLED DEEPEN ❑ RECONDITION C] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT M OTHER ❑ �= <br /> PUMP INSTALLATION [I PUMP REPAIR❑ PUMP REPLACEMENT Q dl . <br /> DISTANCE TO NEAREST: SEPTIC TANK/,,�.r , SEWER LINES PIT PRIVY <br /> µ -r SEWAGE DISPOSAL FIELD CESSPIGOL/SEEPAGE PITT, OTHER <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 l °' rq <br /> Domestic/private Drilled D-i a. of Well Casing 1a ' <br />' :'.Domestic/public Driven Gauge of Casing Jn <br /> Irrigation Gravel -Pack._—...-_Depth-of- Grout Seal_,Y6A <br /> Cathodic Protection- Rotary `Type of. Grout ,e <br /> - <br /> �-�Disposal =� Other ', Other Information- i­� <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor . <br /> k :Type of Pump H.P.•. <br /> E PUMP REPLACEMENT: j]State, Work Done , <br /> PUMP REPAIR: pState Work Done <br /> DESTRUCTION OF WELL: Well 'Diameter ,. Approximate_Depth <br /> Describe Material and Procedure ' Y <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 /> F Health Distr,ict. ' Home owner or licensed agent' s signature .certifies the following: <br /> "I certify that in the performance of the work for which this permit J s 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 /> SIGNED . ,, TITLE: DATE: 1.1'a <br /> DR W PL PLTN ON REVERSE SIDE <br /> T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I� k . <br /> APPLICATION ACCEPTED BY F DATE 7 <br /> ADDITIONAL COMMENTS: Z . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE <br /> Gu 1 n14- ' o„,. '.; .7.7 / �'`- / 1/7 8 2M A <br />