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SAN JOAQUIN LOCAL HEALIH UlS!RIC! <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , -,Stockton, CA 95205 Permit No.Z2F--14 fA: <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> - <br /> This Permit Expires I 'Year From Date Issued <br /> 1 Complete In Tri pl:i cate <br /> 4pplication 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 ;s made in compliance with San <br /> 2oanui n County Ordinance "+o. 1862 and the Rules and Regulations of the San Joaquin Local ,Health <br /> Distract. <br /> ADDRESS "/ /C , �I / CITY/TOWN <br /> EXACTSTREET l <br /> Owner's Name -� l3 '� Phone <br /> City <br /> Address <br /> Contractor' s Nam R:, r ;censei3 Phone ` <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION .INSURAINCE 041 FILE WITH SJLHD? -"YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN El.. . . RECONDITION ❑ pESTRUCTiON❑ zi) <br /> WELL CHLORINATION [3 WELL ABANDONMENT ® OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ . PUMP REPLACEMENTI � <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES. ,. PIT PRIVY Cp <br /> SEWAGE`.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> *, � PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC. WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS= ,., <br /> Industrial_. Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> I Irrigation, t Gravel Pack Depth of Grout Seal <br /> R Cathodic Protection i Rotary Type of Grout <br /> Disposal 1_ Other Other Information <br /> Geophysical { Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump H.P. S . <br /> PUMP REPLACEMENT: 'irate Work Don <br /> PUMP REPAIR: ❑State Work Done <br />'FDESTRUCTIO.N_OF-WELL Well Diameter Approximate Depth <br /> j 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 /> r laws of C aifornia." �. <br /> kI WILL CALL Oft A GRO T iNSPECTI N RIOR © GROUTING AND AL INSPECTION. <br /> DATE �" L Z a <br /> SIGNED TITLE: <br /> DSID <br /> REVERS ER W FLU[ FLAN <br /> FOR EP RTMENT USE ONLY <br /> PHASE 1 DATE 2117 <br /> €APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I N S P E CT I A, By 117F DATE INSPECTION BY r" AT Z "iz$,2% <br /> �. 7 8 " 2M,;, <br />