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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E USE; 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.��- / _ <br /> FOR FFIC }J <br /> Telephone: (209): 466-6781 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> �� <br /> APPLIDate Issued <br /> This Permit Expires f'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 /> Joaquin County Ordinance No. . 1862 and the Rules and Regulations of the- San Joaquin Local Health <br /> District. ' <br /> EXACT STREET ADDRESS ckLzlCITY/TOWN <br /> Owner's Name c./Z_ (.GCt Phone <br /> Add ress 3(1'r ( 5� liV1� .(„fCSVv"5 G/r . City. r �� <br /> ' �S r N -G- f 'ISI � License# Phone <br /> Contractor' s Namef� / <br /> I5 CERTIFICATE OF WORKiiAN'S Co",IPENSATIO+ I"ISURA"10E ON'. FILE WITH SJLHD? YES ✓ NO <br /> TYPE OF WORK (Check) : NEW WELL C _. DEEPEN RECONDITION DESTRUCTIONS <br /> 5 WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 20 t5__r_�L. <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT .[] SU y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES": PIT PRIVY • r=,�A ; ;a ti <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT , ` OTHER <br /> t , ! '� ` PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLICpDOMESTIC.-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 /> J ._ _r - <br /> y }. Domestic/public Driven ' Gauge of Casing <br /> Irrigation; Gravel Pack Depth of .Grout::Seal <br /> f Cathodic Protection Rotary t -Type of Grout <br /> Disposal t t'Other Other Information <br /> Geophysical Surface. Seal Installed b ' <br /> �. PUMP- INSTALLATION: Contractor <br /> Type of Pump ., H.P. <br /> ' PUMP REPLACEMENT: CI State Work Done ` <br /> PUMP REPAIR: C]State Work Done _ <br /> t A roximate De t <br /> DESTRUCTION OF WELL: Well Diameter 4 2 ih pP p <br /> Describe MateriaT and Procedure <br /> 1�4 (. ESDNES SM <br /> I hereb <br /> y ,certify that I have prepared this application and that the work will be done in accordan <br /> k�t,.;. . <br /> �.w7th San J';oaquin County Ordinances , State Laws , and Rules..:and Regulations of the >San Joaquinoca <br /> `;. <br /> F"Health Di-strict. Home owner or licensed agent' s signaturecertifies ctifies 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 toiWorkman's Compensation <br /> laws-of California. " <br /> t I WILL CALL FOR A GROUT INSPECTION PRIOR TO-GROUTING AND A FI.NALIINSPECTION. <br /> ti.r C�i"A IG `w 14 Cry DATE: <br /> SIGNED �' (r: N TITLE: <br /> DRAW PLOTPLA__.,N: ON REVERSE SIDE <br /> FOR DEPA .-ENT !USE ONLY <br /> PHASE I " 4� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHASE_ III INAL INSPECTION <br /> INSPECTION BVDATE INSPECTION BY DATE --- -- <br /> �` <br />