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SAN JOAQUIN IUCAL- HLAL I H UIJ I KIL I <br /> f` FFICE'USE: 1601 E. Hazelton�.Ave'. , :Stockton, <br /> CA 95205 Permit No. ��� <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a-_ _ <br /> Thi's Permit Ex fres 1 Year From Date Issued <br /> Comp]ete IF Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a. permit to construct <br /> dnd/or install the work herein described. T <br /> oaquin County -Ordinance 'No. 1862 and the Rules andlRegulationsication is mofethe San JoaquinwLocalaHealth <br /> D! strict. <br /> XACT. STREET ADDRESS <br /> Owner's Name CITY/TOWN <br /> Address- j t t � - <br /> Phone giR3- <br /> C i ty PU4 <br /> Contractor' s Name !C 10 7 �• License# ' <br /> Phone <br /> r 7S CERTIFICATE OF WORKMAN'S COM PENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL E� DEEPEN ❑ RECONDITION --_� <br /> WELL CHLORINATION Q WELL ABANDONMENT DESTRUCTION <br /> ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ (� <br /> 1, <br /> I DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICDOMESTICINTENDED USEI <br /> TYPE OF <br /> Industria' WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> ( Domestic/private _Drilled <br /> Domestic/public Dia. of Well Casing -� -� <br /> Driven Gauge of Casing <br /> Irrigation _��Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary . 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical �------ <br /> PUMP INSTALLATION: Contractor surface Seal Installed b <br /> Type of Pump H P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe MateT-Idt and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in a o <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San JoaquinLocall <br /> he following: <br /> "I certify that in the performance of the work for which this <br /> not employ any person in such manner as to become subject to Workman's Compensationall <br /> Health District. Home owner or licensed agent's signature certifies t <br /> perm it s issued, I, laws of California. " <br /> I WILL CALL FOR A GROUT INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED <br /> TITLE: DATE: 7 <br /> DR W PL T PL N ON REVERSE SIDE <br />'MASE I FOR EPAR MEN' •US= ONLY <br /> WPP CIL ATION ACCEPTED BY - <br /> 1DDITIONAL COMMENTS: t `-�` DATE 7 <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PHASE III FINAL INSPECTION <br /> DATE /.Z <br /> INSPECTION BY DATE <br />