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Sr--)OAQUIN LOCAL HEALTH DIS"rRICTn <br />,fig {�� L4 CE US-E: 1601 E. Hazelton Ave. , Stockton, CA 9b,uo Permit No. '7�-621Z <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued . " <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This 'application is 'made in compliance with San <br /> oa . <br /> njji/n� County Ordinance r:o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> is'tIyi 1.t. - <br /> XACT STREET ADDRESS .2 j( 7y /j� LS' (i ��i -- -/ _'CITY/TOWN <br /> wne r' s Name Phone <br /> ddress_ 13 j, C�c4 ( �� Ci ty <br /> ontractor' s Name Li cense9 y '_<7;P Phone-3 <br />'S CFRTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES1�N N0, <br /> YPE OF WORK (Check) : NEW WELL C�J— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHE-.RID A <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ISTANCE TO NEAREST: SEPTIC TANK .e/,1,/_ ER LINES PIT PRIVY .•1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> PROPERTY LINE/dE#RIVATE DOMESTIC WELL PUBLIC DOMESTIG,,.WELL <br /> INTENDED USE TYP£OCONSTRUCTION SPECIFICCATIONS ^} <br /> r <br /> Industrial l� Tbbl Dia. of Well Excavation <br /> 2`Domestic/private rql l ed Dia. of Well Casing r o , <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal "�ll <br /> Cathodic Protection __t_Rotary Type of Grout s <br /> Disposal Other Other Information 4 <br /> Geophysical Surface Seal. Installed by: + � <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: ❑ State Work Done <br /> UMP REPAIR: Q State Work Done 't <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ealth 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 /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> laws of California. " <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I G N E D TITLE: DATE: Z Z12 <br /> (DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY j <br /> HASE I <br /> PPLICATION ACCEPTED BY DATE4 IF 7� <br /> DDITIONAL COMMENTS : <br /> PHagE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE 6• . INSPECTION BY DATE Q- `+. <br />•1 cif n r_ <br />