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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Jq <br />-3 nQ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR, PUMP PERMIT Date Issued(l5- <br /> This Permit Ex ires .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 />�'oa0u» County Ordinance 11o . 1862 and the Rules and Regulations of. the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS J 7 cv, CITY/TOWN <br /> Owner`s Name Phone ,`_ <br /> Address City <br /> Contractor's Name leeLicense&f� Phone C ;Z <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL R DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ G� <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER(. <br /> PUMP INSTALLATION E3---- PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .:,jrPSEWER-LI-NES- ---i—PIT-j-P-RI-VY- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_Z21 OTHER <br /> a+ <br /> PROPERTY LINE -. PRIVATE DOMESTIC .WELL Y PUB1: C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable�Tool D:ia. of—Well Excavation <br />�— Domestic/private Drilled Dia.. of Well Casing <br /> SDome�st-i c-/publ i c Driven - Gauge#of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �,E°t_R6tary Type of Grout 1, <br /> Disposal .� .-, --,- -- -'0the'r --�.._.__.,� _ Other I-nformati <br /> .Geophysical -£ Surface- Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f ! <br />,PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t . <br /> I hereby certify that I have prepared this application and that the workiwillbe-.done_in- accordant , <br /> with San Joaquin County Ordinances ,. State-Laws , -and Rules and Regulatian5 of the San Joaquin LocarY � <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." <br /> I WILL CALL F0 A ROUT INSPECTION PRIOR JQ GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED TITLE: DATE: <br /> DR PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S 97 <br /> ADDITIONAL COMMENTS': <br /> PHASE II GROUT INSPECTION ' PHASE III FINAL INSPECTION { <br />',INSPECTION BY DATE INSPECTION BY ATS76 <br /> %koe. <br />'�r r I Ane r,_ - ,., -. i/�,. I �.�]. r-, r� �1_ : ei.,...-e_�9' `'� l 1-70 7 M '-i,' <br />