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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—FOR-OFFICE USE: 1601 L Hazelton Ave. , Stockton, CA 95205 Permit No: -ice <br /> Telephone: ' (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued- i-� <br /> This Permit Expires 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 /> Joaquin County 'Ordinance No. 1862:{and the Rules' and Regulations, of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN �. <br /> Owner's Name Phone <br /> Address I - City ,. ._ <br /> Contractor's Name fAr_1;4r.f,,V A License 22,7 x hone <br /> a 3 S+ _ _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOt INSURANCE ON FILE WITH_SJLHD.?_... -YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION] <br /> WELL CHLORjINATION ❑ WELL ABANDONMENT., OTHER❑ <br /> PUMP INSTALLATION❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSP-?OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATT- q-URESTIC WELLPUBLIC DOMESTIC -WEfT— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing . <br /> Irrigation -1 Gravel Pack Depth of Grout Sea <br /> Cathodic Protection .i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor' w <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> D£STRUCTION 'OF WELL: Well - Diameter ApproximateYDepth- ' , <br /> De sc ibe to al "And Proc izes <br /> 7" <br /> I hereby certify that I have prepared this .application and that the work wi 1' bane it oP'd�i'8e <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or lilicensed 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 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED' TITLE: , - .-DATE: I <br /> (09AW PLOT PLAIT ON REVERSE SIDE) <br /> , FOR DE M SE ONLY <br /> PHASE I <br /> PAP LICATION ACCEPTED. BY DATE `��C- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> . INSPECTION BY. DATE .; INSPECTION BY DATEZf -7 <br /> CU 1d9a Mau 17_77 ;; 1 2M. <br />