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SAN JOAQUIN LOCAL HEAL:IH UIS TRlt;l <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION,-OR PUMP PERMIT Date Issued/2 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In TYiplicate <br /> Application is hereby made to the San Joaquin Local. Health District fdr a permit to construct' <br /> and/or install the-work herein..described. . This application is made in compliance with San <br /> k2oaquin County Ordinance No. 1862 and the ,Rules and, Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ^I CITY/TOW . <br /> Owner's Name - <br /> zu Jr D p e C� - -- -- Phone <br /> T <br /> Address QFC/�! / r61ir. ,�r C.;ty/i41reif' a✓' . _ <br /> Contractor's Name Li censeV f X&f Phone —3PzS_. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR ;CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M— DEEPEN-0- RECONDITION ® DESTRUCTION(3 <br /> WELL CHLORINATION L WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TANK714r SEWER LINES_ 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 �1`� <br /> _LDomestic/private Drilled Dia. of Well Casing_ ____ <br /> Domestic/public:,'L Driven Gauge of Casing t��� • /�O - _ ' <br /> Irrigation Gravel Pack Depth of Grout Seal x? <br /> Cathodic Protection A­Rota'ry Type of Grout C_ ��reoc.% r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 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 INSPECTION RRIOR,TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 14 <br /> DR W `PLOT FPL N ON REVERSE SIDE <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED_ BY ODATE 1-1113199 <br /> ADDITIONAL COMMENTS ./ <br /> a /s 7 <br /> PHASE II GROUT INSPECTION PHA I F INSPECTION <br />, INSPECTION BY DATE INSPECTION BY DATE f 2/-,V z <br /> Cu I A13C r)_ 11 n -?� l 1762 7m <br />