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c SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Stockton, CA 95205 Permit No. <br /> r � Telephone: (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�.�, ? <br /> x <br /> (Complete In Triplicate) <br /> Application is hereby made-.to th'e, San"Joaquin Local Health District for a permit to construct <br /> and/or i'nstal.l the. work- herein. described. This application is made in compliance with San . <br /> Joaquin County Ordinance No' 1862 and the Rules and' Regulations of the San Joaqui o 'A th <br /> District. . 72 ch <br /> EXACT STREET ADDRES -� � � � <br /> �0 <br /> Owner's Name �-~' Phone <br /> Address - 7 + <br /> G C ty <br /> Contractor's Name- License 12-9,J Phone_ - �C <br /> IS CERTIFICATE OF WORKMAN'S COf"PENSATION INSURAINCE ON FILE WITH-SJLHD? YESNO:.. <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION [] DESTRUCTION Q <br /> WELL �C✓+ILORINATION Q� �WELL ABANDONMENT 0 OTHER fj <br /> PUMP INSTALLATION LIQ PUMP REPAIR 0-- RUMP REPLACEMENT <br /> DISTANt -TOrNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC A- _ :_ <br /> - Ind-us ial TYPE OF-WELL,.. ; ' `� CONSTRUCTIMSPECIFICATIONS <br /> _ _.Industr.ial Cable Tool Dia. of Well Excavation �I <br /> _Domestic/private Drilled Dia. of Well Casing •1 <br /> ______Domestic/public Driven <br /> Irrigat ionGauge of Casing s �j <br /> Gravel Pack Depth of Grout Sea <br /> _,...Cathodic Protection Rotary y Type of Grout , <br /> Geophysical Othe Other Informat_Io= r��x ,-=Surface 1 Ins'ta -- <br /> PUMP INSTALLATION: ' <br /> Contractor �� � <br /> Type of Pump H. .t <br />-PUMP REPLACEMENT: r <br /> State Work Done p <br /> RUMP REPAIR: : <br /> - ❑State Work. Done � <br /> DESTRUCTION OF WELL: Well Diameter r <br /> Describe Materldl and Procedure Approximate depth <br /> 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 Sin Joaquin �Local <br /> Health -District: Home owner or licensed agent's signature certifies the followid <br /> "I certify that .in the performance of the work for which this permit is issuedg�iI shall <br /> not employ any person in such manner as to become subject to Workman's Compensation " <br /> laws o alifarnia. " <br /> I' WILL CA OR A GR UT INSPECTI R 0 GROUTING AND NAL INSPECTION. f, <br /> SIGNED �� �_ E., ..�e.. <br /> F.r TiTkE:- .�- - ---DATE: <br /> _. <br /> D W P L N ON REV E , <br /> PHASE I <br /> 0 EP TNEEN. S ti-ONLY' <br /> P�LICATTION ACCEPTED BY <br /> OD'I T I ONAL COMM . . T t. . ---.w m, _ __ .. <br /> 1wNTS -...__,.. DATE, <br /> PHASE TIG ITT IitISAECTI.ON <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br />; <br /> H 74 26 Rev. 917 INSPECTION BY DE 7d 7 <br />