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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> OR FFICE US 1601 'E. Hazelton Ave. , Stockton, CA 95205 -""_ Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 3 �� <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 /> ,'oaqu,n County Ordinance No 1862- and the Rules and Regulations of the San• Joaquin .Local Health i <br /> District. <br /> EXACT STREET ADDRESSCITY/TOWN- '�<_/C_ tom- - <br /> Owner's Name n od g!L._��� T`/Zv a e�_ � - _ _ Phone_ <br /> Address ' <br /> Contractor's Namev' n. t1 /. License#, 6576 / Phone i g _ <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE r! FILE- WITH SJLHD? YES 4, NO � <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHL-OR-I,NATI-ON"❑- .WE—L ABANDONMENT,❑- OTHER❑ <br /> PUMP INSTALLATION Com— 'PUMP REPAIR❑ PUMP REPLACEMENT [j <br /> DISTANCE TO NEAREST: SEPTIC TANK_]"r SEWER LINES PIT PRIVY r <br /> SEWAGE DISP SQ AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN W PRIVAT DOMESTIC WELL _462` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> c. Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing__ ,b I <br /> Irrigation Gravel Pack Depth of Grout Seal A. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information t <br /> Geophysical 0 y Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contra for " <br /> Type of Pumpiq <br /> H.P.�J �► <br /> PUMP REPLACEMENT: CjState Work Done - <br /> PUMP <br /> one -PUMP REPAIR: ❑State Work'�Done <br /> DESTRUCTION OF WELL: Well Diameter I Approximate Depth <br /> Describe Materia and- Procedure _ r <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 licensed agent's..s-i.gnature 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. " i <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ TITL DATE.3 <br /> '" - DR W �L �TP ON RE RSE SIDE <br /> t <br /> -FOR-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III'FINAL- INSPECTION <br /> INSPECTION BY 3 So 1-7K- DATE INSPECTION BY DATE <br /> EH Td2A Rai, 79_77 ... _ _... .. _ 1 /7Q 7N[ <br />