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Al L <br /> SAS' JOAQUIN LUCAL. HEALIH UISIRICI <br /> FOR FFICE USE: 1601 E azelton Ave. , 'Stockton, CA 9 5 Permit No. -11 9 <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a <br /> This Permit Expires 1 Year From Date Issued <br /> (Complete In Trip icate <br /> Application is hereby made to the San Joaquin Local Health .District for a permit to construct <br /> and/or installothe,work herein described. This application is made in .compliance with San <br /> oanuin County.•Ordinance No. 1862 and the Rules. and Regulations of the San. Joaquin Local Health � <br /> District. <br /> EXACT STREET ADDRESS 43 q r z� `'� CITY/TOWN r a, <br /> Owner's Name p Phone <br /> Address .� 'A tA City <br /> Coptractor' s Name License# �_ Phone S 3 U <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES I/ NO <br /> TYPE OF WORK (Check) : NEW WELL •DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ,0 WELL ABANDONMENT 0 OTHER 0 ltl <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ Ic <br /> Ic <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation <br />_Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing S <br /> Irrigation Gravel Pack Depth of Grout Sea \ <br /> Cathodic Protection Rotary Type of Grout .� <br /> Disposal Other Other Information <br /> - - Geophysical \\ \ Vurface Seal Instal ed b : <br /> PUMPINSTALLATION: Contractor <br /> Type of Pump - fr W 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 Proce ure <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 Loca- <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 GR T I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED . TITLE: " DATE: <br /> W PLOT PLAN ON RLVE S E <br /> • FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A P—LIGATION ACCEPTED BY 0ATEv2- -Z- <br /> ADDITIONAL COMMENTSC . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE3%,2j—� <br />