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SAN JOAQUIN,,LOCAL.,HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton 'F1ve. ,y Stockton, CA 95205 Permit No. <br /> Tel.ephohe �`;(-209) 466-6781 <br /> 4 Date issued !/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thus Perm7t' Ex gyres l?YYear"'From. Date Issued <br /> . �.. . Corgi 1 ete I n TetpI i cats Y <br /> t .-4. <br /> • �{ - nstruct <br /> ' :co <br /> I 'Application is hereby made to the San Joaquin -Local Health.;District ,for..a permitf.to 00 <br /> and/or insta1l'r.the,.work,;herei,n descri-bed.: .This* <br /> app1,icati.on. is ,.made in compliance .with San <br /> oaqu i n .County, ;Ord i,nance- bio.; 862 .and :the Runes .and Regul ati aids lofthe. 5.an Joaqu i ri. Local Health <br /> `District. j� ,. <br /> R .S . , ..., CITY/TOWN ' 9 <br /> EXACT STREET ,ADD ES <br /> "Phone (� <br /> Owner's Name w <br /> AddressQ r _ _ _ _... City <br /> Contractor' s Name 1 �� License# Phone x Z'2-- <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATI0111 THIW A"10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Che.ck).: NEW WELL 0 DEEPEN Kr RECONDITION Q DESTRUCTION E3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER FJ - <br /> PUMP INSTALLATION G�' PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL ,FIELDJ� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC �DOMESTIC WELL <br /> f CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --- Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection otary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical % Surface Seal Instal <br /> PUMP INSTALLATION: Contractor <br /> Type :of Pump H <br /> PUMP REPLACEMENT: CIState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter J Approximate Depth <br /> Describe.Material-and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> } with San Joaquin .County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 /> F not employ any person in'such manner as to become subject tol.Workman's Compensation <br /> laws of California." <br /> k I. WILL CALL R A- GROUT INSPECTION PRIOR GROUTING AND A FINAL 'INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W L L N ON REVS SE. SIDE <br /> FOR DEPARTMENT -USE ONLY <br /> PHASE I _ DATE <br /> 1 APPLICATION ACCEPTED BY -6�� <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D� <br /> s <br /> ] /7. M <br /> _ f.. • - _ <br /> EH 1426 Rev. 12'"-77.- s _ <br />