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SAN JOAQUIN: LOCALi EiEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton,Ave. ; Stockton, CA 95205 Permit No. ;FT 32 2 <br /> Telephone:_ (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT pate Issued <br /> This ,.Permit .Ex ires 1 Year :From Date I,ssded <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 incompliance with San <br /> Joaquin County--Ordinance No. 1862' and the Rules and Regulations of the San. Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name - Phone <br /> Address �. . . city �r 14o, _� l <br /> Contractor's Name ,yLicense# 1 Phone_ / -J7 �[� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO": INSURA"Irr 0� FILE WITH SJLHD? YES NO <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN CI RECONDITION DESTRUCTION[D <br /> WELL CHL R NATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TAN K,�D � <br /> SEWER LINES � PIT PRIVY �-•- <br /> SEWAGE DISPZSL, FIELD�� CESSPOOL/SEEPAGE PIT - OTHERPROPERTY LI --(PRIVATE DOMESTIC WELL,*�20FUBLIC DOMESTIC WE'LL -- ­tA <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Y. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal ! <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst ed b , <br /> PUMPINSTALLATION: Contractor 7_r <br /> Type of Pump <br /> PUMP ' REPLACEMENT: Q State Work Done a <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter A ,Approximate Depth <br /> Describe Material and Procedure <br /> II I hereby certify that I have prepared this application and that the -work—w-1.11 be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and- Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> E "I' certify that in the. performance of the work for which ythAs permit is- issued, I shall <br /> not employ any person in such manner as to become subje,ct ,to Workman 's Compensation <br /> laws of California." <br /> I WILL OR A G^ NS TO GROUTING ANDyA FINAL INSPECTION. <br /> SIGNEf TITLE: DATE• <br /> (DRAW PIOT PLAN ON REVE ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION _ _ �. PHASE. III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 /7R <br />