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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No." <br /> »Telephone: (209) 466-6781 <br /> rV� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -< -/�-7 <br /> This Permit Expires 1 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 -21120 A6�� 1.146117-H7- M/[ h- CITY/TOWN s 7OG,4-TON <br /> Owner's Name F� �N 7 �� T Phone 9Y� .33 <br /> Address_ P D S <br /> "":� 3�'7 City ��l1GiJ' 7lN <br /> Contractor's Name ' ,,Ag/{ IA11/Z 4 fdy1P ;zy4ticense#7�j>�z Phone yGl_ S� ly <br /> IS CERTIFICATE OF WORKMAN'S CO"4PENSATION INSURANCE ON FILE WITH SJLHD7 YES JC NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION C3DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK N°" P�S'ErW )2-il S �11/, <br /> 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 Weli Excavation <br /> Domestic/private Drilled Dia. of Well Casing_ <br /> AF <br /> Domestic/public Driven Gauge of Casing /Q op <br /> Irrigation Gravel Pack Depth of Grout Seal 15-0 <br /> Cathodic Protection Rotary Type of Grout ,&&Y7aN/T% <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor C /,�,z' li/!,/j �j� 01P GG. �/�/G. <br /> Type of Pump P. <br /> 2 <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: ❑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 IPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE:_ S7 �y'A DATE:/F//7/1 )/ 747 <br /> N <br /> DR W PL T PL ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> ,PW hJI GROUT INSPECTION PHAS III FIN L INSPECTION <br /> INSPECTION BY DATE_ 5 a4 lq INSPECTION BY DATE 6-14-11 <br /> EH 1426 Rev. 12-77 1/38, 2M <br />