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SAN JOAQUIN LOCAL-HEALTH DISTRICT '"'Y� . <br /> HE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. j <br /> -._Telephone: (209) `466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit- Expires 1-:Year From Date Issued <br /> C'ompl ete In' Tri pl i cate <br /> Application is hereby made to the San Joaquin Local Health District for a permit .to .construct a <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 k <br /> District. <br /> EXACT STREET =ADDRESS 2!20 'j� Ada E /gip CITY/TOWN S7ac,&TON <br /> Owner's Name Pee IAI Phone 9 L—3 3 <br /> Address City Is <br /> if1GeY TG1'l. -Contractor's Name j /t L�.� 6g p1-P Ct)1*6 i cense# Phone YLg_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHL RINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST: , SEPTIC TANK N°`u �xS'E'W �I S 'f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 W ll Casing <br /> Domestic/public, Driven Gauge of Casing ld. <br /> Irrigation Gravel Pack Depth .of Grout Sea <br /> Cathodic Protection Rotary Type of Grout G _1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> � ?1?.k '���� FCjol ..F,. -_ — <br /> Typep <br /> o ........ - - -. H-P._77; <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordancE <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 I PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �79 <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />-TPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P I GROUT INSPECTION PWAS III FIN L INSPECTION - - <br /> INSPECTION BY DATE 5-44-19 INSPECTION BY DATE <br /> EH 1426 Rev. 12777 1/78, 2M <br />