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SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> _F�R- QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �q -65S <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> \ 1 (Complete In Triplicate) <br /> Application is hereby rade to the an Joaquin Local Health District for a permit to construct <br /> and/or install the work herein ibed. This pplication is made in compliance with San <br /> Joaquin County Ordinance No. 18 nd the Rules d Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS l "k Ami, CITY/TOWN <br /> Owner' s Name Phone <br /> Address �.zal_za c f2�'/ City���'� f�I <br /> Contractor' s Name / O'lLCS PV ov® , License# S- 13 Phone q419-"17 <br /> IS CERTIFICATE OF 0i'K"IAN'S C014PENSATIO"J INSURANCE ON FILE WITH SJLHD? YES & NO �. <br /> TYPE OF WORK (Check) : NEW WELLJX DEEPEN ❑ RECONDITION [] DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER O <br /> PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4.._� SEWEf NES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT__,52�017HER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -5i2±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 Well Casing <br /> Domestic/public Driven Gauge of Casing JX <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: Contractor <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: 17 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 accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Nome 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 WILLCALL A GR UT I TION TO GROUTING AND FIN INSPECTION. <br /> SIGNED :TITLEDATE: 1;7 <br /> DRAW PLOT PLAN ON REVERE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY �,,„ DATE__/ Y `T9 <br /> ADDITIONAL COMMENTS : <br /> RASE II G �'T INSPECTION PHAS III FI L NSPECTION <br /> INSPECTION BY DATE 9-'c4+1o1 INSPECTION BY ATE 9_18.11 <br /> LH 14 26 Rev 78 5/79 211 <br />