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SAN JOAQUIN LOCAL HEALTIH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. e-,�� <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 2 <br /> This:Permi t Exp i res 1 Yn.r-F.rpm -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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San' Joaqu-in Local Health <br /> District. r1 ll <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name o Phone. <br /> Address <br /> +a . . . city <br /> dress is Name License# PhoneContracto <br /> IS CERTIFICATE OF WORK?IAN'S COMPENSATION IINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WE-LL9LDEEPEN ❑ RECONDITION ® DESTRUCTION[2 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK (,p r SEWER LINESJVW 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 e <br /> >Irrigation Gravel Pack ---Depth of Grout Sea <br />` Cathodic Protection , Rotary Type ,of Grout _ <br /> Disposal Other Other Information <br /> E r:GeophysicaT : Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor - <br /> Type o'f Pump H.I <br /> PUMP REPLACEMENT: ❑Stalte Work Done <br /> PUMP" REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I havelprepared this application and tliat--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: -A <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 WLLL CALL FOR A GROUT NS CT 0 PRIOR TO GROUTING AND A FI NAL INSPECTION. <br /> TITLE: DATE: 6 ,� <br /> (DRAW PLOT P N ON REVERS SIDE <br /> y FOR DEIII <br /> RTMENT USE ONLY <br /> ' PHASE I DATE 'L <br /> ! APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT J NSPECTIO PHA II IN INSPECTION <br /> INSPECTION BY �/' _ DATE WI INSPECTION S -- DATE 3-012- <br /> _ - g 2M <br />