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SAN JOAQUIN 10CAL HEALTH DISTRICT <br /> FOR OFFICE -USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: '(209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ]� <br /> This Permit Ex ire's 1' Year From 'Date Issued , <br /> Complete In Triplicate ' <br /> , Application is hereby made to the San Joaquin Local Health• District fora permit to construct <br /> . and/or-install the -work herein described. This application ,is made in compl:iance `with San <br /> : uoanuin County Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health <br /> t <br /> District. r. <br /> EXACT STREET ADDRESS f CITY/TOWN <br /> Owner' s NameI Phonet3�5=Fl3 4,_ _ <br /> Address _ Ci ty <br /> Contractor's Name License "Y7/ Phone <br /> IS CERTIFICATE OF WORKMAN'S`{COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES 1C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN CI RECONDITION ❑ DESTRUCTION E] <br /> WELL;CHLORINATION Q WELL ABANDONMENT p OTHER( v <br /> PUMPJINSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [] ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI7 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 /> Domestic/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 instal—led b <br /> PUMP INSTALLATION: Contractor r <br /> M Type:"of Pump H.P.-?;k <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr i be Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <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. " if <br /> I WILL CALL F A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �4 TITLE: DATE:-T— L7Y <br /> if (DRAW PLOT PLAN ON REVERSE SIDE)_ <br /> II FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1,4A DATE . <br /> ADDITIONAL COMMENTS : iIf <br /> PHASE II GROUT ,INSP CTION PHASE IIS INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT5!!� <br /> kPP 1A.9A . . Dok. 19-77 , - 1178 2M <br />