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�ni <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: E. Hazelton Ave. ," Stockton, CA 95205,EQR <br /> Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued."� <br /> This .Permit Ex ires 1. Year From Date Issued. t <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' appl,ication is made in compliance with San <br /> Caaquin County Ordinance No . 1862 and the Rules and 'Regulatiohs of the San.: �oaquin Local Health. <br /> Di str ct. ±I fro Ga o 2S/ —l7d <br /> EXACT STREET ADDRESS ,4 �'- - <br /> TY/TT-OvWNN.� � . <br /> Owner's Name Phone <br /> Address _ kdCity <br />; Contractor's Name License# Phone g� — g Z3 <br /> t: <br /> IS CERTIFICATE OF WORK AN'S COMPENSATI011 IINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Er DEEPEN ❑ RECONDITION ❑ DESTRUCTION[:) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 1 OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C] I <br /> DISTANCE TO NEAREST: SEPTIC TANK� SEWER INES AlPIT PRIVY-M/4 4 <br /> t SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE P T OTHER ' <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLSIC DOMESTIC WELL <br /> fes. <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation I - <br /> Domestic/private Drilled Dia. of Well Casing L2I + <br /> Domestic/public riven Gauge of.Casi ng <br /> Irrigation Gravel Pack .Depth of Grout Seal gyp' <br /> Cathodic Protection --��Rota-ry-- "" " Type of Grout -- Q <br /> f Disposal Other ;; Other' Information <br /> 4 Geophysical <br /> Surface Seal Installed b <br /> ' PUMP INSTALLATION: Contractor = 1 <br /> Type of Pump H. . <br /> : PUMP REPLACEMENT: []State Work Done <br /> { <br /> ; PUMP REPAIR: ❑State Work Done <br /> IiDESTRUCTION OF WELL: Well Diameter tri Approximate- Depth <br /> Describe Mate ria - 6 _P_roce a ure-----, — <br /> jI hereby certify that I have prepared this application and that the work will be done in accordant <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: Y <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 F ROUT INSP CTION PRIOR TO GROUTING AND A FINAL,-INSPECTION. /g <br /> SIGNEDTITLE: DOF ATE: <br /> (DRAW PLOT PLAN ON REVEITSE SIDE <br /> FOR DEPARTMENT USE ONLY 1- <br /> PHASE I DATE Z <br /> APPLICATION ACCEPTED BY u� <br /> -ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C - ATE I <br /> g�z 7/1� O`'w"V <br /> �}j 1426 Rev_ °12-77"""'......, — _ _� _ 7.8�: 2M. <br />