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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No. r79 -7 <br /> Telephone: (209) 466.-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 2s 3? 2 <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin -Local Health District for a .permi-t.to construct. <br /> rand/or install the work herein described. This application is made i.n. compliance with San <br /> 'oaQuin County Ordinance 14o. 1862 and the Rules and Regulations of th"e,,San Joaquin Local Health <br /> CtiStr�Ct. <br /> k EXACT. STREET ADDRESS;. CITY/TOWN <br /> Owner's Name Phone M==Z,2 Q <br /> Address - <br /> City <br /> Contractor's Namezaa <br /> License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION 111SURMICE ;ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION DESTRUCTION[j <br /> WELL CHLORINATION Q`I WELL ABA-NDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION El PUMP REPAIR 5' "-PUMP REPLACEMENT E] <br /> DISTANCE TO (NEAREST: r-SEPTIC TANK SEWER LINES, PIT PRIVY <br /> t= SEIAGE:_QiSPO;SALE FIELD CESSP00L/SEEPAGE PIT OTHER <br /> . �� <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE"-`- - TYPE 0 WEELL CONST�tI�CT�OfV SRECIFICATIONS <br /> r Industrial Cable Too! Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -Irrigation <br /> G6avel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of, Grout <br /> Disposal Other #" i0ther Information <br /> ` Geo .- tSurface Seal Installed by: <br /> 1 PUMP INSTALLATION: :�'itohtractor <br /> ` :10 Type of Pump H.P. <br /> '. PUMPt;REPLXEMENT: y .p Statee Work Done �, <br /> , <br /> PUMP REPAIR: 5aState Work Done 4' 9)71012 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material an2 Procedure <br /> I k <br /> { <br /> � I hereby certify. that I have prepared this application and that the work will be done in accordance <br /> iwith 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 /> 1I WILL CALL R A GROUT SPECTION .PRIOR TO GROUTING AND IN INSPECTION. <br /> E <br /> SIGNED TITLE DATE: �Q'� <br /> Ii DR W PLOT PLAN ON REVERSE SIDE <br /> I PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ZZ2 If <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE IIT INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE DATE <br /> i . <br /> EH_ 1426 Rev_ 12-77 - 1 /7R 2 <br />