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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />=FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 PermitN <br /> Telephone: (209) 466-67817 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue <br /> This Permit Expires I Year From Date Issued ` <br /> M .Complete In Triplicate Fk <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 /> 1oaqu;r County Ordinance 14o41862 and the Rules and Regulations of the San Joaquin- Local Health <br /> District. .� <br /> EXACT STREET ADDRES'S J 91 CITY/TOWN <br /> Owner' s NameA x0-M,n c <br /> `� ��` � Phone, 6r <br /> Address — _ City <br /> Contractor's Name Livens Phone d w,'a- / <br /> IS CFRTIFICATE •OF WORKMAN'S COMPENSATIOI'l INSURA"ICE"ON FILE=ITH SJLHD? YESND <br /> TYPE OF WORK (Check) : NEW WELL L�}rDEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER O � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST : SEPTIC TANK,&0 EWER L`INES . - PIT PRIVY ` <br /> SEWAGE DISPOSAL FI LD ' CESS'POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ,. <br /> INTENDED USE TYPE-OF- WELL—— CONSTRUCTION SPECIFICATIONS <br /> D <br /> Industrial . '` ` ' �_C01e Tool''. - ',-,:.Dia- of Well Excavation l a1 <br /> _Domes tic/.prigat�e Drilled ~ Dia. of Well Casing - ;? <br /> Domestic/publlc� `. �DrVen '"'y' '� "` " <br /> Gauge of Casing <br /> Irrigation - Gravel"'Pack� "Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal .T; : , Other Other Information <br /> Geophysical'•-",• _ Surface Seal Installed b <br />-PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0Sate Work Done <br /> I <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth gin. Y <br /> Describe Material and Procedure <br /> iI hereby certify that I havellprepared this application and that the work will be done in accordance <br /> Iwith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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 EPR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />'.SIGNED <br /> TITLE: DATE: <br /> 0 DRAW PLT PLN ON REVERSE SIDE <br /> PHASE I �N FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY IZ�t� 6zd <br /> DATE <br /> ADDITIONAL COMMENTS: w; F€ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE. INSPECTION BY DATE -7 <br /> SEH 1426 Rev . J?-�77 P s�f�l Q'�`-� -Zj`/. 78 2M_ <br />