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f M ' <br /> SAN JOAQUIN YL'OCAL- HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79—/1�-- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - -7f <br /> This Permit Ex ices 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. -t-- <br /> EXACT STREET: ADDRESS : 5 � CITY/TOWN <br /> Owner's Name Phone_ ��j (Q� <br /> Address— <br /> Contractor's <br /> ddress Contractor's Name - � , License# Phone 3 <br /> f IS CERTIFICATE OF WORKMAN'S CO""PENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN a RECONDITION C] DESTRUCTION <br /> WELL CHL RINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 2- PUMP REPAIR O PUMP REPLACEMENT [I <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 SPECIFI_CATIO_N_S_ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �6mestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing 5 t4-n <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 ' - <br /> Type of Pump H.P. <br /> PUMP- REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR R OUT INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE• DATE: 37 <br /> (DRAW PLOT PLAN ON REV ID <br /> FOR DEMRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT E <br /> 1ADDITIONAL COMMENTS: <br /> PHASE iI GROUT INSPECTION PHASE ITL FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B1 DATE S <br /> f Gu 7A7r- o,,., 713 �� ` �7 /7A' )m <br />