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SAN JOAQUIN .LOCAL HEALTH UIS I RIC I <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�� <br /> Telephone: ' (209) 466-6781 l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued K <br /> This Permit Ex ire`s 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 /> Joan-u i n County Ordinance °No. 1862- and the Rules and- Regulations. -of the San Joaquin Local .Health <br /> District. <br /> EXACT.STREET ADDRESS 4 7 L'� CITY%TOWN 4dall' <br /> Owner' s Name 9A - 1�-A /�ca,WWI'' Phone <br /> Address QdL_ City /f <br /> Contractor's Nam ` ' License# AS 9Phone e <br /> IS CERTIFICATE OF WORKMAN'S GalfeENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> -t <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ® OTHER ❑ _ <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT 5a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other . Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor L1` ke <br /> Type of Pump H.P.. b--. <br /> PUMP REPLACEMENT: PState Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 in such manner as to become subject to Workman's. Compensation <br /> laws of California. " - <br /> I WILL CALL FOR A GROUT INSPECT P I GROU ING AND A FINAL INSPECTION. <br /> SIGNED - LE: DATE: <br /> —r",J/ <br /> W PLOT PLKN ON REVERSE SIDE <br /> FOR-DEPARTMENT USF ONLY <br />( PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 e <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION -PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Gu TA99 oe„ 97_77 1 /78 2M A <br />