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SAN JOAQUIN LOCAL: HLAL I H Ul,J I KIL <br /> FOR QFFICE USE: 1� 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No.7F'_//s3 <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ _ <br /> This Permit Ex ires 1 Year From Date Issued <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 in compliance with San <br /> , oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> D' strict. <br /> EXACT STREET ADDRESS . ,3 CITY/TOWN <br /> Owner' s Name C Pi Phone <br /> AddressA [lam City�,c , +, :. <br /> . — <br /> Contractor' s Narrie y ��� License _ z7 Phone ff a,�2L) <br /> etc) <br /> IS CERTIFICATE OF WORKMAN'S 011PENSATIOIN I'JSURAINCE ON FILE WITH SJLHD? <br /> ;.YES :: _ -:. ,JD <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT J�@ - OTHER <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP `REPLACEMENT C1 <br /> ,'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERI <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Weil-. 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 Installed by: <br /> PUMP INSTALLATION: Contractor �'��7c��tf &)Aj <br /> Type of Pump -- - , H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: : Well Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordancl <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 GROUT INSP I PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> .(DRAW PLOT PLKN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: IF <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> � 1 <br /> INSPECTION BY DATE / INSPECTION BY DATES <br /> FW 1 A 7 G o,... 1 1) '77 M,r..:; , r a 1, <br />