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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE US 160I. E. Hazelton Ave.­,,- Stockton, CA 95205 Permit No. ,�-3 <br /> Tel ephone:..w (209) 466-6781 <br /> APPLICATION FOR WEl.L_. CONSTRUCTION OR PUMP PERMIT Date Issued!/_7_-T" <br /> ssued 3/ <br /> This Permit Ex ires. l YearFrom 'Date Issued <br /> Complete In Triplicate <br /> lApplication is hereby made to. the San Joaquin'.Local Health District far a permit to construct ' <br /> and/or install the work herein described. ' This -application .i,s made in compliance with San ' <br /> Joaquin County Ordinance No.: 1862 and the Rule5,4nd Regulations of the San Joaquin .Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone-,v6 <br /> Address -_Xy��� <br /> City f 6^i <br /> Contractor's NameLhVi Ve/I Lai <br /> _ License# <br /> Phone <br /> Pl <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATInm INSURA"CE ON FILE WITH, SJL•HD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN C] RECON-D'ITION Q DESTRUCTION[� T <br /> WELL CHLORINATION d WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT 99--- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL —7PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> . Domestic/privateDrilled Dia. of Well Casin:g- <br /> Domestic/public Driven Gauge_of,Casin.g, }` , <br /> M 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 ' <br /> 1 Type of Pump H.P. <br /> Aa <br /> PUMP REPLACEMENT: g4State Work Done v ry f <br />` PUMP REPAIR State Work Done ccs <br /> Q <br /> DESTRUCTION OF- WELL: Well Diameter ` <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 licensedkagent'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 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED I TITLE: <br /> E SID DATE: . <br /> DR W PLOT PL N ON RE <br /> FODEP RTMENT USE ONLY <br />� PHASE I 24 <br /> APPLICATION ACCEPTED BY DATE ,� <br /> ADDITIONAL COMMENTS: <br /> /,�4� <br /> °PHASE II GROUT INSPECTION <br /> PHASE III FINAL INSPECTION <br />'I,INSPECTION BY DATE INSPECTION BY DATE 3-2-7-7J <br /> 426. Rev. _12=77 <br />