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-EQBSAN JOAQUIN LOCAL HEALTH UISTKIC; E <br /> FFICE USE: 1601 E. Hazelton, Ave..., Stockton, CA 95205 Permit No._y�_11R`d <br /> Telephone: (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued_y— <br /> _ <br /> This 'Per`mit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health :Distr.ict fora permit to construct <br /> and/or install the work herein described. This a.pplication,,.is made in compliance with San . <br /> Joa(iui n County Ordinance No.. 1862- and the .Rules .and Regulations of the San Joaqu n Local Health <br /> Eistrjcl- <br /> EXACT STREET ADDRESS .1 CITY/TOWN�c e v, <br /> Phone <br /> Owner's Name 5 <br /> Address City_ <br /> Contractor' s Name �Q S Li cense Phone <br /> IS CERTIFICAT E*-OF--WO RKMAN'-S-•-COMPENSATI-O'N-INSUfirF-Om-FILE W1,T-H-SJb-HD?—Y-E-S- N4 <br /> TYPE OF WORK (Check) : NEW WELL DEEPENED 'RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ED OTHER 0 ` <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK/,M4--SEWER LINESZM-"4_PIT PRIVY------,- <br /> SEWAGE <br /> RIVY ---SEWAGE DISVOSAL CESSPOOL/SEEPGE PIT THER "-" o <br /> ` Pdzrt <br /> ROPERTY LINPRIVAT.E .DOMESTIC WEL PUBLICOTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 7' omesti c/private A-1-ri 11 ed � Di a._of„ Wel l.,, as i ng <br /> Domestic/public Driven z:—'Gauge of Casing ; <br /> Irrigation �G avel Pack Depth of Grout-Seal �-- <br /> Cathodic Protection d4Rotary ,•.:. Type'of Grout <br /> Disposal Other -Other 'Information <br /> Geophysical ,� y�:� . ; Surfa:ce• * , <br /> Seal Installed b : ' <br /> PUMP INSTALLATION: Contractor J Y, S <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: ❑State Work Done ; <br /> PUMP REPAIR: ❑State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate`. Depth <br /> Describe Material and Procedure <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 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 ;;ih.,11 <br /> such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A, GJOUT INSPECT.I:QN PRIORJO GROUTING AND A FI AL INSPECTION. <br /> ED <br /> DATE: zl <br /> SIGNTITLE: <br /> DR LOT P.L N ON REVERSE SIDE <br /> FOR DEPARTMENT 'USE ONLY <br />'rPHASE I <br />,APPLICATION ACCEPTED BY DATE / S <br /> ADDITIONAL COMMENTS : <br /> PHW IJ GROUT INSPE-CTJOq PHASE, III FINAL INSPECTION <br /> INSPECTION BY DATE ! INSPECTION BY DATE � 7f <br /> rw 1d7F Pau 17-77. _ _ - <br />