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or►c I���r." SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> F Stockton, CA 95205 Permit No.W!V_:L_ <br /> ,'�=USE; 1601 E. Hazelton Ave. , <br /> &4ew IsTelephone: (209) 466-6781 Date Issued 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires ,l Year From Date Issued <br /> ComT <br /> plete In riplicate <br /> Application is hereby made tothe r he 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 /> L',oaou i n County Ordinance 1�o. 1862.and the Rules and Regulations of the San ,Joaqui Loa 3Health <br /> 2-30 D i s t r c+ _2�f3o ,..5'....D,P�--t-r~�4-�� ' �� 1493--'CITY/TOWN <br /> EXACT STREET ADDRESS �l� . o ' r�r•s a� CITY/TOWN ' r ' <br /> Phone <br /> Owner' s Name <br /> Address -70 v7t,J A-V­ city. <br /> Contractor' s Name <br /> License# l hone <br /> IS CERTIFICATE OF WO(?Kr1AN' C ��1PENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO_________ <br /> TYPE.. <br /> OF WORK (Check) : NEW WELL❑ DEEPEN,❑ RECONDITION C] DESTRUCTION❑ =� <br /> ' <br /> WELL CHLORINATION El WELL ABANDONMENT p OTHER <br /> { PUMP INSTALLATION ❑f PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> AF PROPERTY -LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC JELL <br /> INTENDED USE . <br /> TYPE OF }WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing dl, <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Gravel 'Pack Depth of Grout Seal � . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b r <br /> y f-6PUMP INSTALLATION: Contractor. H.P. �S"v <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done y <br /> k' PUMP REPAIR: f�3State Work Done <br /> k, DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr-ibe Materia an . Prate ure <br /> II hereby° certify that i have prepared this application and that the. work W 1 be done-in accardanc <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 INSPE N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED "ITLE: DATE:—V-2 <br /> DR PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /-,J2-�Il' <br /> !APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE) 4 2 _ <br /> 18 <br /> '1A 77 <br />