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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: V1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2f_Z _ <br /> Telephyone: (209) 466-6781 ^" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedf1 <br /> This Permit Ex fres l 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. <br /> EXACT STREET ADDRESS 14-4..0 f �Z J-1/! E p .4 CITY/TOWN ',Le9a j, - <br /> Owner's Name ." , 1 Phone. <br /> Address _/ l /t - `DISC I;P-p City, Z-a"421 <br /> Contractor's Name A5061 -.3.3 7 - <br /> �1 �- �I21 L1�l��__- L3 censer 1,���Phone - , <br /> IS CERTIFICATE OF Wgr,,KMAN'S' CO"1PENSAT I0!T7TN1 SURANCE­ON--FILE"WITH s-JLHD? YES, 'NO <br /> TYPE OF WORK'(Check) : "NEW�WELL BX �DEE�PEN C[ - RECONDITION ❑ ' —DESTRUCTION❑ n�� <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER ❑ _ - - <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST : SEPTIC TANK_&5- SEWER LINES (05-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE)WPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL : <br /> INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial t Cable Tool Dia. of Well 'Excavation <br /> Domestic/;private Drilled Dia. of WelliCasing. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigat-i-on ? Gravel Pack Depth of Grout Seal <br /> Cathodi:d- Protection Rotary Type of Grout e S4,e <br /> Disposal' . Other Other Information'` <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: i Contractor <br /> Type of Pump ; H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: �Y# ❑State Work Done <br />' DESTRUCTION OF WELIE: Well Diameter - .-Approximate Depth <br /> I—Desc-ri-be-Mater.i-a- andRr-oce ure <br /> I hereby certify that••1-have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances., 5tate°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 thatin ;the performance of ' <br /> the work for which this permit is issued, I shall <br /> not employ any person4J'n' s-uch manner as to become subject to Workman 's Compensation <br /> laws of California":" <br /> I WILL <br /> SIGNED CALL FOR A GROUT-INSPECTION PRIOR TO GROUTITLEAND A FINAINSPECTION. DATE: //_/ -7 Oe <br /> DRAW PLOT �LTN 4N REVERSE SIDE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDi_BY - _ DATE. <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTMN PHASE III FINAL INSPECTION r <br /> INSPECTION BY� DATE �-- �'�� INSPECTION BY [✓ : DATE / L , 6 �� <br />