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A <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />-F,OR FFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No. '7 -'.- 2427 <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ 3-7 <br /> This Permit Ex fires 1 Year ,Froin Date Issued <br /> Complete In Triplicate)_ <br /> Application is hereby made to 1the 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 />'oaauin County Ordinance No 1862 and the Rules and•,Regulations of the San Joaquin Local Health <br /> Distr�Ct. . <br /> EXACT STREET ADDRESS CITY/TOWN 9(,�i� _ <br /> Owner's Name - Phone — � <br /> Address City <br /> Contractor's Name L i c e n s e# /r7 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMRENS_ ATIO'N IEISURA"ICE 4ON FILE WITH SJLIiD. YES NO -_ <br /> TYPE (OFR.WO.RK ,(,Check) : NEW._,;WE1 LO, DEEPEN 0 R'ECOND'ITIONAa DESTRUCTION E]WELL`' C'KLORTNATION p WELL ABANDONMENT 0 OTHER I� � <br /> PUMP INSTALJLATION Q PUMP REPAIR❑ PUMP REPLACEMENT*K "� s <br /> DISTANCE TO NEAREST: SEPTIC TAMC ! SEWER LINES' PIT PRIVY <br /> k` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONiSPECIFICATIONS <br /> Industrial Cable Topl -µ Dia. of Well Excavation <br /> . ,, � <br /> Domestic/private .., Drflled Dia. of Well Casing <br /> Domestic/public 'Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary r Type of Grout <br /> Disposal Other 1 Other Information <br /> Geophysical E Surface Seal Installed b : # <br /> PUMP INSTALLATION: Contractor. <br /> Type of PumpH.P. <br /> k <br /> PUMP REPLACEMENT: State Work Done <br /> A 0- <br /> PUMP REPAIR: QState Work Done f --- - - - g. - <br /> DESTRUCTION OF WELL: Well Diameter 7�-, .'�-ApPraximate Depth <br /> Describe Material and ProceKi4 .y �' " ` •'"� <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 NS CTION PRIOR TO GROUTING AND A FINA NSPECTION. <br /> SIGNED TITLE: € DATE: _ <br /> DRAW--`PLOT,-PL N ON REVERSE SI E a <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY4 _~ DATE 174�- -7? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT, INSPECTION , PHASE III F AL INSPECTION <br /> INSPECTION BY DATE � INSPECTION BY DATE � <br /> FH 1 AnC 11) 77 q /7W 2II_ A <br />