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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7f-J-71 <br /> Telephone: (209) 466-6781 - <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thi.s PermitEx i,res 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 /> land/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.. <br /> EXACT STEET, ADDRESS' Zz 0 A S'. C' L4 Kri I P n A't• CITY/TOWN <br /> Owner's Name r or Goer -1 . Phone •• -r' 5`z1 <br /> Address. City_, Ill e y <br /> f Contractor's Name ic. x+c �� License#/f7d'o3 Phone Cy-7 13� `' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> i — <br /> `. TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [] RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION Pa PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 /> Domestic/private Drilled Dia. of Well Casing N <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 Instal ed b <br /> PUMP INSTALLATION: Contractor *A I— A,Llic TitI C <br /> Type of Pump 3S H.P. <br /> > <br /> I[ PUMP REPLACEMENT: F]State Work Done <br /> SPUMP REPAIR: QState Work Done <br /> ,, DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> IDescribe Materia and Proce ure <br /> rI hereby certify that I have prepared this application and that the work will be done in accordan <br /> ° with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: coo 13�` DATE: G �� <br /> (DRAW PLT VL_FN ON REVERSES E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE — <br /> . APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III . FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT- E <br /> _, , — 4A '. ' 1/78 2M <br />