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SAN JOAQUIN. LOCAL HEALTH DISTRICT - <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .Sto,ckton, CA 95205 Permit No.� <br /> Telephone; (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued X/;7,V <br /> This Permit Expires 1 Year From.Date Issued MAI L �o CI rclj' <br /> Complete In Triplicate ��f NA 1:.. c711 <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- in compliance with San" <br /> I,_oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joagdin Local Health <br /> District. <br /> EXACT' STREET ADDRESS CITY/TOWN <br /> . cAtoj <br /> Owner' s Name Ry _ Z�1�1b IAI __ . Phone <br /> Address 8��� �� ��MQr� City <br /> Contractor' s Name s�-p�tYL -uts License#_ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> r <br /> TYPE OF WORK (Check) : NEW WELL LJ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 _ �? <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [] v, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> . PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing_ <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information { <br /> Geophysical Surface Seal Installed by: <br /> PUMP -INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby certify that I have prepared this application and that the work will 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 /> "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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED e�< TITLE : -.__ DATEj_ 0 <br /> DRAW PLOT PL N ON REVERSE- SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II NAL I PECTI.ON <br /> INSPECTION BY DATE INSPECTION BY ATE <br />