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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. %Hazelton Ave. , Stockton,- CA .95205 Permit No. q- U <br /> Telephone: (209) 466-6781 <br /> z Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (fomplete 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 /> Joaquin County Ordinance No. 1862 and the Rules and ,Regulati°ons of the San Joaquin Local-Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN U <br /> Owner's Name <br /> A AJ Phone ` <br /> — c9 <br /> Address zi _ �" Ci ty <br /> Contractor's Name � � CA License# Phone <br /> TS CERTIFICATE OF WORKMAN'S COF"PENSATION INSURA"SCE ON FILE WITH SJLHD? YES NO' <br /> TYPE OF WORK (Check) : NEW .WELQ?' <'DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 � <br /> PUMP INSTALLATION, PUMP REPAIR p a PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. . , . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP 0L/SEEPAGE IST OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL_-r_-___ PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> Industrial TYPE OF WELL CONSTRUCTION SPEC.IFIGATIONS <br /> CTool Dia, of well Excavation <br /> —Domestic/private Drilled Dia. of Well Casing <br />:!!Sable <br /> Domestic/public Driven , Gauge of Casing / 1 <br />::!!� <br /> Irrigation Gravel Pack-k-` Depth of Grout Sea <br /> Cathodic Protection Rotary ' Type of Grout , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal InstalTed b'UMP INSTALLATION: Contractor - it <br /> Type of Pump i" H.P._ ' <br />'UMP REPLACEMENT: ❑.State Work Done <br /> IUMP REPAIR: Q State Work Done <br />►tSTRUCTION OF WELL: Well Diameter Approximate Depth ? <br /> Describe MatJial and Procedure <br /> hereby certify that I have prepared this application and that-the work will be done in accordance <br /> ith San Joaquin County Ordinances, State Laws , and. Rules and Regulations of the San Joaquin Local <br /> i�alth 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 ;s <br /> qkNlaws. alifornia. <br /> WI.LL;C LL 'R G UT INSPECTION PRIOR TO -GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: DATE: 1—�L1757 <br /> (DRAW-P-L-7 PLA9ON REV—ER—F SIDE <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> P� LICATION ACCEPTED{ BY , <br />)DITIONAL COMMENTS: DATE <br /> PHA E I ,GR0 INSPECTIO pHRS III FINAL INSPECTION <br /> dSPECTION BY DATE INSPECTION BY DATE <br /> i 14 26 Rev. 9/7 9178 2M <br />