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SAN JOAQUIN LOCAL H,EALIH. UISIKILI i <br />� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br />' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT- <br /> Date Issued//-,? <br /> a <br /> This Permit Expires 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 /> 4oaquin County Ordinance No. 1862 and the -Rules and Ry <br /> ulations of the San. Joaquin Local Health <br /> District. X78-90 S L,aw� prs <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone��(!� _ Ui_ _ <br /> Address k r Ci ty /r7.4ry !S Zj� <br /> Contractor' s Name Li cense"w Phone_017 jrl6 _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION TN IIPA� r.F ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW 'WELL DEEPEN [:1 RECONDITION [] DESTRUCTION❑ E <br /> WELL CHLOIZINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK!, SEWER LINES ppb PIT PRIVY Ip1)I (-�, <br /> SEWAGE DISPOSA FIELD��gg / CESSPOOL/SEEPAAGE PIT - OTHER <br /> PROPERTY LINED OPRIVATE �DOM-ESTIC WELL' PUBLIC DOMESTIC WELL ---- Oaz <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout C <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 GROVT IN81PTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE:,Z,2 <br /> (DRAW PLOT PL N ON REVS SID <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A � DATE / �! <br /> ADDITIONAL COMMENTS: _ <br /> IN8W I . GROUT IRSPECTroPHASE III INAL INSPECTION <br /> INSPECTION By DATE �`—= INSPECTION BY D DATE <br /> CLI h R7c n_.. n fiii 1 170 7M <br />