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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 �/ <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1 a/ <br /> hk <br /> /� This . Permit .Ex ires 1 Year' From Date Issued <br /> 1 3 ' 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. ?his application .,is made in compliance with San <br /> Joaqui,n:County Ordinance No. 1862 and the Rules and .Regulations of the San Joaquin Local Health <br /> District. , <br /> EXACT STREET ADDRESS CITY/TOWN c <br /> Owner's Name - Phone A:P&kms 2 �---- <br /> Addresscazu City, <br /> Contractor's Name ,,� Licens Phone �J- <br /> IS CERTIFICATE OF WORKMAN'S 011PENSATIO'N I'MSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL, CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> .� ,. PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENT [] r <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINE5!�-,944 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _.OTHER <br /> PROPERTY LIN21614PRIVATEE DDORESTIC WELL,/LL..-� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation J2 <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ---YGravel Pack Depth of Grout Seal �lZ� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe b <br /> PUMP-INSTALLATION: Contractor <br /> r <br /> Type .of Pump <br /> H.P. <br /> r> f <br /> PUMP; REPLACEMENT: ❑State Work Done 3 <br /> PUMP REPAIR: Q State Work' Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth 2Q <br /> Describe Materia a Proce ure <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. Horne 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 Cal-ifornia. " <br /> I WILL C FOR A GRO T INSP TX TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: I. DATE: / <br /> D W PL T PMN ON REVERSEiISIDEL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED_ BY DATE � <br /> ADDITIONAL COMMENTS : <br /> P A -I GROUT INSPECTION PHASEFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE 7-2-r-- <br /> �� <br />