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SAN JOAQUIN. LOCAL HEALTH UISTRICi <br /> ;_E4 FFTCE USE: 1641 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No. <br /> Telephone: . (209) 466-6781 <br /> � 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued d _7 <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made t�o the San Joaquin Local . Health <br /> ermit <br /> and/or install the work hereiin described..._This application Distma'de ' inrict rcompliancetwith nSanuct <br /> I Loaquin County- Ordinance Noi, 1862 and the Rules and Regulations of the Sart Joaquin Local Health <br /> Dstrict. <br /> EXACT STREET ADDRESS 7 SA <br /> CITY/TOWN 7 <br /> Owner's Name -- <br /> Phone 1 <br /> Address <br /> 31 City <br /> Contractor's Name , <br /> License# Phone, <br /> . SLa� <br /> ="S CERTIFICATE OF ldORK Ar41S C0"TPENSATI N I"dSURANE ON FILE- WITH SJLHD? YES 0 <br /> �— <br /> ------------- <br /> TYPE OF WORK (Check) : NEW WELL L1 DEEPEN ❑ RECONDITION ❑ DESTRUCTI <br /> O <br /> WELL ',CHLORINATION 0 WELL ABANDONMENT a OTHER �� <br /> PUMP 414STALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> .'DISTANCE TO NEAREST: SEPTIC TANK /o o SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE" PIT OTHER ~ <br /> v <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> Industrial TYPE OF WELL : CONSTRUCTION SPECIFICATIONS • O! <br /> Cable Tool Dia. of Well Excavation <br /> ��omestic/private ' Drilled Dia. of Well Casing <br /> Domestic/public Drivers Gauge of Casing <br /> Irrigation p Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: 'Contractor_: . <br /> Type off. Pump H.P. <br /> PUMP REPLACEMENT: Stalte Work Done <br /> PUMP REPAIR: ❑Sta:te Work_ Done, <br /> DESTRUCTION OF WELL: Well Drameter <br /> Describe Materia and Procedure ..Approximate Depth <br /> I hereby certify that I have• p"repared this application and that the work willbe doneinaccordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local'. <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the <br /> not em to not of the work for which this permit is issued, I shall <br /> P Y an y person in such manner as to become subject to Workman 's Compensation <br /> Taws of California. " .fill <br /> I WILL CALL F G UT IN5PEC_1ION 2RTnR TD GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: - <br /> R W PL T PL N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY � �_ <br /> 4DDITIONAL COMMENTS: l <br /> PHASE II GROUT INSPECTION <br />'NSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY _ <br /> DATE <br />',H -1.426 --Rev_., - 2-7_— w .-11P, <br />