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SAN JOAQUIN.L9AL,.HEALTH DISTRICT <br /> FOR FFICE USE: V 1601 E. Hazelton'."Ave. , "Stockton, CA 95205 Permit No. <br /> Telephone:'.. (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued o 3 7� <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> jApplication is hereby made to the San Joaquin Local Health District for a. permit' to construct <br /> and/or install the work herein :des.cribed. - This. applicati.an is made in compliance with' San ' <br /> ,'oanuin County Ordinance No. 1862 and the Rules and Re lations of the 'San Joaquin Local Health <br /> C,istrjct• J13yJ � �# <br /> EXACT STREET ADDRESS trac,f CITY/TOWN 1., de.,,- <br /> Owner' s Name Phone <br /> City <br /> Address a <br /> � �' <br /> Contractor' s Name juef2<Aij License# Phone <br /> IS' CERTIFICATE OF WORKMAN'S COMPENSATION INSU �•!CE ON FILE WITH SJLHD?. YES 4-- NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION[2 <br /> WELL CHLORINATION,;,❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION 0�— PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK&02�:� SEWER LINES ' PIT PRIVY ! <br /> + SEWAGE DISP SO ALJIELD CESSPOOL/SEEPAGE PIT OTHER " <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial4 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 Installed by: <br /> PUMP INSTALLATION: Contr4ctor-/JA.1,'.1/-01-g fcz {- <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordi.na.nces , 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 GRO T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: ew4. DATE: <br /> DR W PLOT PL7N ON REV SE SIDE r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 0 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> I I 4E� <br /> VFH1VF ._..--- <br />