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SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> CA 95205 Permit No.— <br /> Telephone: ' <br /> OFFICE USE: 1601 E. Hazelton Ave. Stockton, f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER <br /> Date Issued <br /> This Permit Ex ires 1. Year From Date Issued <br /> j Complete .In Triplicate <br /> lApplication is hereby made to the San Joaquin Local-. Health District for a permit` to construct <br /> and/or install the work herein described. This appl-Reationi s madfetin conpliancenwi.with <br /> San <br /> Health <br /> 'oan-1,i n County -Ordi nance .No.1 1862 and the .Rul e5 and g <br /> yl Gistr�ct. j� � <br /> CITY/TORN <br /> EXACT STREET ADDRESS <br /> s l Phonet'�_O� <br /> Owner's Name a <br /> Address <br /> r License <br /> Contractor' s Name / Phone �" r <br /> r <br /> IS CERTIFICATE OF WORKMAN'SJCOMPENSATIOP! INSURA^10E OPd FILE WITH SJLHD? YES <br /> ff '' DESTRUCTION[� <br /> ITY11 OF WORK (Check) : NEW WELL DEEPEN Q RECONDITION ❑ -OTHER F-3 � <br /> WELL,CHLORINATION ❑ PUMP REPAWELL DIRND NT QMP REPLACEMENT 0 <br /> PUMP I yI NSTALLAT I ON ' <br /> , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Domestic/private -Drilled -Dia.Dia. of- Well Casing - <br /> �- <br /> Domestic/public �^" Dri Ven s.Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> IrrigationRotary Type of Grout <br /> Cathodic Protection <br /> Disposal Other Other Information <br /> Surface Seal Instal ed b <br /> Geophysical <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> k <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: we I I I D i ame t e rApproximate Approximate Depth <br /> Describe Materia and Procedure <br /> ; I hereby certify that I have prepared this application and that the work will be done in accordai <br /> !with. San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loci <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> I "I certify that in the performance of the work for which this permit is issued, I shall <br /> hot 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• DATES--43� -?r <br /> : SIGNE ;� TITLE: . <br /> i DR W PLOT PL N ON - REV E SE SIDE <br /> FOR DEPARTMENT USE ONLY �- <br /> PHASE I DATE_ ��_zp <br /> (APPLICATION ACCEPTED BY <br /> 1ADDITIONAL COMMENTS: <br /> RP �1 . F NAL INSPECTIONPHASE II GROUT INSP CTIONDATE ' �- <br /> jINSPECTION BY DATE INSPECTION BY <br />