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/ SAN JOAQUIN LOCAL HEALTH 01MICTFOR Permit No. �S_1�31 _ <br /> FFICE USE: r/ 1601 E. Hazelton Au_.e.-„ ,S�ockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued$ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date. lssued <br /> I Complete In Triplicate <br /> hereby made tofthe San Joaquin Local Health District fora permit to construdt ` # <br /> Application is he y {l <br /> and/or install the work herein described. This -application is made in compliance with San <br /> Joaquin County Ordinance No. .1862 and the Rules- and Regulations of the San Joaquin Local Health <br /> District. <br /> `I, CITY/TOWN <br /> EXACT STREET ADDRESSA. <br /> Fs, <br /> Owner's Name I! Phone `�� � - <br /> Address City <br /> Contractor' s Name License ' Phone <br /> IS CERTIFICATE`OF I40RK'1Af.I'S-00*,IPENSATI-O'I- I'1SURA, CE-ON FILE WITH SJLHD? YES '10 <br /> -���. . <br /> TYPE�OF WORK (Check}: NEW WELDEEPEN [:] RECONDITION Q� DESTRUCTION(�� <br /> WELL CHARNATION Q WELL ABANDONMENT C1 OTHER 0 <br /> PUMP INSTALLATION Ca : -PUMP'. REPAIR 0 � PUMP REPLACEMENT0 � <br /> DISTANCE TO NEAREST: TAN SEWER LINE �-( PIT PRIVY TS -- OTHER �1 <br /> SEWAGE DI5 AL FIELD % C SSPOOL/SEEPAGE PI <br /> PROPERTY LIN��`'�RI.VA DOM STIC WELL PUBLIC DOMESTIC WELL <br /> I� INTE-NDED- USE. _ TYPE OF WELL vi ! CONSTRUCTION .SPECIFICATIONS <br /> --Industrial Cable Tool Dia. of Well Excavation- <br /> Domestic/private Drilled Dia. of Well Casing c�'`: `r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ,Gravel Pack Depth of, Grout Sea . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal � "'�'`- `� �'� <br /> O her � " `iOther-Information � <br /> Geophysical Surface Seal Inst 1 ed b <br /> PUMP INSTALLATION: Contractor-%t\ <br /> Type of Pump r <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> D£STRtiCTION~O WELL: Y' WellDiameter. *` Approximate Depth <br /> Describe Materi'al and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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.” 11 <br /> I WILL CALL FOR A OUT INSP CTI P 0 TO (ROUTING AND A FINAL INSPECTION. <br /> TITLE: - Ku DATE: <br /> SIGNED L T P N ON REVERS SIDE <br /> t <br /> FOR DEPART ENT USE ONLY <br /> PHASE IE DATE r <? <br /> I APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE IIIjFINAL INSPECTION <br /> PHASE.,I? GRO T;jINSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> ' 0 '4�, _ '1[7 8, 2M <br />