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FFICE USE. SAWN JOAQUIN LOCAL HEALArH DIST CT <br /> l iHazelton Ave. , Stockton, <br /> TeleTelephone: C75 Permit No. 2r <br /> p (209)456-678I � — <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue _ z15 <br /> (Complete In Triplicate). <br /> aplication is hereby made to the San Joaquin Local Health District for a permit to cons <br /> Id/or install the work herein described. This application is made in compliance with San pct Q <br /> 3aquin County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health V <br /> strict. . . l <br /> ,ACT STREET ADDRESS <br /> Iner's Name CITY/TOW <br /> dress Phone <br /> ntractor's Name. City. <br /> L i c e n s ef322JJq Phoney <br /> CERTIFICATE OF WORKMArs'S CO"4PENSATIOrI INSURA"1 ON FILE WITH 7 <br /> TH SJLHD. YES 0 <br /> 'E OF WORK (Check) : NEW WELL 0 DEEPEN Cj. RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER � "4 <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> ....ANCE TO NEAREST; SEPTIC TAN r I <br /> SEWAGE DISpOS �QER LINES PIT PRIVY <br /> ES <br /> PROPERTY LIN�4f PRIVAT�E�D�STICPW�LLSE��.-z PUgGE � OTHER <br /> INTENDED USE —DOMESTIC WELL <br /> Industrial TYPE OF WELL <br /> Cable Tool CONSTRUCTION SPECIFICATIONS- <br /> Domestic/private Dia, of Well Excavation <br /> Domestic/public Drilled Dia, of Well Casing � <br /> Irrigation --- Driven Gauge of Casing j <br /> Cathodic Protection —�—Gravel Pack Depth of Grout Sea -- <br /> Disposal —Othery Other of Grout <br /> Geophysical --- er Information <br /> Surface Seal Instal ed by: <br /> ' INSTALLATION: Contractor <br /> Type of Pump <br /> ' REPLACEMENT: H• <br /> R`Ems: <br /> State Work Done <br /> C State Work Done <br /> RUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Mate— <br /> Uldl and Procedure <br /> reby certify that I have _ <br /> prepared this application and that the work will be done in accordance <br /> San Joaquin County Ordinances, State Laws , and Rules and Regulations of the: San Joa uin Local <br /> h District. Home owner or licensed agent's signature certifies the following: 4 <br /> I certify that in the performance of the work for which this permit is issued, 'l shall' <br /> not employ any person in such manner as to become subject to Workman's <br /> laws of California. Compensation <br /> "_L CALL FOR A 0 CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ;D <br /> DR L TITLE: <br /> ON REVERS rDE DATE: 2 <br /> I FOR DEPARTMEN U5E ONLY <br /> C <br /> 11TION ACCEPTED 8Y oQ <br /> 'IONAL COMMENTS: DATE ,- 77 f' <br /> PHASE II GROUT INSPECTION <br /> PHASE III FINAL INSPECTrON , <br /> CTION BY DATE <br /> INSPECTION BY <br /> 26 Rev. 9/7 <br />