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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ErIC£ USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 ?-,5--L <br /> ` Telephone: (209).466-6781 <br /> -? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued, - _,3 <br /> This °Permit Expires I- YearFrom 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 /> 2istrict. (: . <br /> ' EXACT-STREET ADDRESS 3 I ! Sc�, I.u�� _ __ CITY/TOWN <br /> { Owner's Name Phones 4 <br /> AddressLJ City <br /> Contractor' s Name License# Phone <br /> 'S CERTIFICATE OF WORKHAN'S COMPENSATIO"! I''3SURA"ICE ON FILE W1TH SJLHD? YES *d0 <br /> k TYPE OF WORK (Check) : NEW WELLL3 DEEPEN ❑ RECONDITION [2 DESTRUCTION[ <br /> WELL CHLORINATION WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION;( PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iPIT PRIVY <br /> k SEWAGE DISPOSAL FIELD CTSSPO-Gb/,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 4el`1 'Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary . 'Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical ..-- Surface Seal�Insialled-b <br /> PUMP INSTALLATION: Contractor, <br /> Type of Punrip _Sl�A - ` �e _ H.P. ' <br /> PUMP REPLACEMENT: ❑State Wort, Done <br /> PUMP REPAIR: Q State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materiai and Proce' fare. <br /> I hereby certify that I have p,reparedr-this applicati•o;n and that the work will be done in accordar <br /> with San Joaquin County Ordinance s.•;` State Laws , and"Rbi os and Regulations of the San Joaquin Loca <br /> r Health District. Home owner or lice"used£ 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 manners 'to\ become subject to Workman' s Compensation <br /> laws of California." i, <br /> r I WILL CA UT IN PECTION PRIOR TO' GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITTLE: DATE: . =� -? <br /> (DRAW PLOT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE -- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FN 1x.99 Rau 19-77 . <br />