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SAN JOAQUIN LULAL HLALIH UI5IRILI <br /> FFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 LDa <br /> rmit No.Z .l-f�� <br /> Telephone: (209) 466 -6781 <br /> * teIssued _ -J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> a,nd/or install the work herein described. This applica.ti.on is made In compliance with San <br />;'oanu�n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. _ � <br /> EXACT STREET ADDRESS � i <br /> CITY/TOWN ze . <br /> Owner' s Name Phone <br /> Address City , <br /> Contractor's Name ice nseWPhone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N IfJSURA CE ON FILE WITH SJLHD? YES l/ 140 <br /> TYPE OF WORK (Check) : NEW WELL U DEEPEN L7 RECONDITION Q DESTRUCTION[2- <br /> WELL CHLORINATION E3 WELL ABANDONMENT 0 OTHER{ � <br /> PUMP INSTALLATION Ka-' PUMP REPAIR❑ PUMP REPLACEMENT [a <br /> DISTANCE TO NEAREST: SEPTIC TANK�A� EWER LINES�.�A�J T PRIVY -- <br /> SEWAGE DISPO IELD CESSPOOL/SEEPAGE PIT 0 ETHER <br /> PROPERTY LINPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Do <br /> dustrial Cable Tool Dia. of Well Excavation!� mestic/private Willed 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 /> w Geophysical Surface Seal Installed b <br /> 1PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />! PUMP REPLACEMENT: State Work Done <br /> ' PUMP REPAIR []State :Work Done <br /> DESTRUCTIONYOF WELL: ' Well Diameter _Approximate. Depth .__-_ .- - <br /> Descri,be7Mate'rlal and Procedure <br /> r <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 Local <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 s_:uch __ina6ner as to become subject to Workman's Compensation <br /> laws of California. " <br /> kI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A INSPECTION. <br /> SIGNED TITLE: DATE: <br /> R W PLOT PL REVERNIINAL <br /> k FOR DEPARTMENT USE ONLY <br /> ,PHASE I DATE Z <br /> iAPPLICATION ACCEPTED Y /Z <br /> 'ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 1INSPECTION BY DATE lo- ta- �� INSPECTION BY DATE j/ : <br /> - - -- - -- -- <br /> 1/78 2M <br />