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SAN JOAQUIN LOCAL HEALTH DISTRICT �C �- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-.7T-Z/ <br /> f Telephone: (209) 466-6781 <br /> - ---- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /7�7 <br /> This Permit Ex ires 1 Year From Date Issued <br /> L.chc(SE A-U1'=- : 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. Thisapplication 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. r� <br /> EXACT STREET ADORES O)YJIN � CITY/TONIN <br /> 0wner' s Name J )5j Phone <br /> Address es / 7\1 f9t-1 City <br /> Contractor' s Name J-9-261 A4 Li cense# �3rJ�Phone 4L <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE 'ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK '(Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT ❑ <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. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q 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 accorda <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Lac <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: E:Z.. - 7y <br /> (DRAW PLOT PLAN ON REVERS SIDE) <br /> m <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 'PHASE. II: GROUT .INSP.ECTION J. PHASE IIT FIlV I E T <br /> INSPECTION BY DATE . :INSPECTION BY <br /> SEH 1.4.26..�_._.Rev': �12�7?. :_ ._.. �/.�$.. -"2M°. <br />