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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit N0.2 9 4�y , <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete IF—Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health .District for a permit tb construct <br /> and/or install the work herein described. This-application is made in compliance with San <br /> ,' Joaquin Local Health <br /> oaouin County Ordinance, No. 1862 and the Rules and Regulations of the San <br /> District. <br /> EXACT STREET ADDRESS IZ b� S� �-w�" �L.Gf CITY/TOWN <br /> Owner' s Name �il/c _ r Phone <br /> Address S ,� City <br /> ,Contractor' s Name` S . License# Phone <br /> IS 'CERTIFICATE OF WORKMAN'S C0111PENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION DESTRUCTION[3 <br /> WELL CHLORINATION C3 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT � <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <br /> C 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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor S /f <br /> Type of Pump r.� l� H.P. <br /> PUMP REPLACEMENT: []State Work Done <br />'PUMP REPAIR: ' Q State Work Done <br />[ DESTRUCTION OF WELL: Well Diameter Approximate Depth ~� <br /> .Describe Material an2 Procedure <br />, I hereby, certify that I have prepared this application and that the work will be done in accordanc( <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." I - - <br /> rI WILL CAL1, FOR A GROUT 3NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: /9 <br /> . .(DRAW PLOT PLKN_ ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 12 <br /> 1 /79 �M <br />