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r- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Q FR 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br />'kms Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> C, <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 Joaquin Local Health a <br /> District. <br /> EXACT STREET ADDRESS g QAl 1 <br /> f4 CITY/TOWN T/[ <br /> Owner' s Name _ki Phone <br /> Address �� e X_Y7 City <br /> Contractor' s Name G J License# I Phone - �'/ <br /> TS CERTIFICATE OF WORK'1,AN'S C0`1PENSATI i`f INSURANCE ON FILE WITH SJLHD? YES NO <br /> I TYPE OF WORK (Chu(k) : NEW WELL 0 DEEPEN ❑ RECONDITION p_ DESTRUCTION[J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ , <br /> PUMP INSTALLATION PUMP REPAIR❑ }-PUMP REPLACEMENT [J ; <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE--D-IS-POSAL- FIELD _5-04- CESSPOOL/.SEE-PAGE PIT — OTHER <br /> PROPERTY,LINEi-' PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE ,OF"WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -. _,.­Cable Tool Dia. of Well Excavation ' <br /> omestic/private ' x Drilled Dia. of Well Casing Off <br /> Domestic/public Driven r Gauge of Casing <br /> Irrigation ,� �' ­­Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection—i''; Rotary Type of Grout <br /> Disposal- y , . .Other Other Information x� <br /> Geophysilc-al p1 '' Surface Seal Installed by: <br /> ti PUMP !NSTALL TION', Contr ctor <br /> Type df Pump H.P. <br /> PUMP REPLACEMENT: a ❑State Work Done <br /> PUMP REPAIR: � ❑State Work Done � a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t _ <br /> I hereby certify that I havelprepared this application and that the work will be done in accordance <br /> with,�-Sa-n-Joaq.u-i-n-Ceu.nty-Ordinances-,:,Stat.e-Laws-,-a.nd-Rul.e.s-and3Reg.u_l_at-ions of the San Joaquin Local <br /> Health District. Nome owner For 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 . <br /> I WILL CALL A OUT SPECTION PRIOR TO GROUTING AND F AL INSPECT N. <br /> SIGNED TITLE: _ DATE: <br /> DR W PL T PL N ON REVER E7,aSI E ,"' <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I � <br /> APPLICAACCEPTED BY DATE /7TION <br /> ADDITIONAL COMMENTS : A <br /> PHASE II GROUT INSPECTIONf PHAS III FINAL INSPECTI �. <br /> INSPECTION SY �� s�.. DATE \-->S INSPECTION BY DATEL -41 <br /> 4° CH 14 26 Rev. 9/78 5/ 1 <br />