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SAN JOAQUIN .LOCAL HEALTH DISTRICT OFFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205" Permit No. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expire-, 1 Year� From Date Issued ' <br /> Complete In Triplicate) ! Z-030-25 <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 /> Joaquin County Ordinancetilo. 1862-anld-'the Rules and Regulations `of the San Joaquin Local Health <br /> District. 5 Dive Aim".{ ILS " J� <br /> EXACT STREET ADDRESS e CITY/T4 <br /> Owner's Name Phone <br /> Address .�.?9/ Ltd, /Gl d ~�! I l7�-- = -- City. LJ&��� - -- <br /> Contractor's Name '� License# Phone <br /> IS CERTIFICATE OF WORKMAtVS COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLOQ DEEPEN ❑ RECONDITION ® DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PIMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C] � I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION 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 X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout (11514—ew 71L <br /> Disposal Other Other Informationah 161,f A7J A4 I <br /> Geophysical Surface Seal Installe b+: fI <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> — <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: LIState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> IN <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. 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �1TITLE: DATE:_ . / - <br /> i�. <br /> - (DRAW PLOT PtN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY �: DATE 7, <br /> ADDITIONAL COMMENTS . <br /> PHAS II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION B 11. DATE INSPECTION BY DATE <br /> EH 1426 Rpu 19-77 �� 1 /78 2M -i <br />