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r J� SAN JOAQUIN LOCAL HLAL1H UISIRIUf <br /> ;__EQ FFICE USE: 1" 1601 E. Hazelton Ave. , -Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,;?_,, G_ <br /> This .Permit Expires 1 Year From Date Issued . <br /> 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. This application is made _ in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of: the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS r 7 "- Z, o i�1 CITY/TOWN <br /> Owner's Named 12 Phone ' / � i <br /> Address ' City.��G�4 <br /> Contractor's Name `fes. ��,� ,� Licensee/� Phone <br /> .'S CERTIFICATE OF WORKMAN'S COFiPENSATIO"! INSURANCE ON FILE- .WITH .S.JLHD.? YES -. <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] r�3 <br /> WELL CHLORINATION p WELL ABANDONMENT ED OTHER FJ {''1 <br /> PUMP INSTALLATION ❑ PUMP REPAIR)a PUMP REPLACEMENT [� t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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 F <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 -0 ther Other Information <br /> Geophysical _ ! Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor - rte f <br /> Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: _. [] State Work Done <br /> PUMP REPAIR: MState Work Don e } <br /> DESTRUCTION OF. WELL: Well, Diameter g <br /> Approximate Dept h <br /> 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 , StateLaws , and Rules and Regulations of the San Joaquin Local] <br /> Health"District:' Home owneror 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. " E <br /> I WILL CALL- R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �--f <br /> URAW PLT L N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY q <br /> APPLICATION ACCEPTED BY DATE 7a /� 7 e !' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL I PECTION <br /> INSPECTION BY DATE_ •_. INSPECTION BY ;�� ATE 7 <br /> IA9A D- <br /> f �' <br />