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SAN JOAQUIN LOCAL HEALTH DISTRICT -----.- <br />-EOR 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 <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 /> ,.'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS .f-:57 e'er X/ CITY/TOWN ✓ ' ' j <br /> Owner's Name , tL, ; �-�, r s .,� �`' Phone �.3 i - e> -7 3 , <br /> Address ✓ 4?s' ? /L,/ i A-/ 4P City <br /> Contractor' s Name 164Da ko 4e, c� LL 2;-4-1-/A'E ti cense# ,i ce phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO1111 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELD-- DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK >0661 SEWER LINES >lBaa� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD>lwo, CESSP00L/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 / i.." a. I: <br /> Domestic/private Drilled Dia. of Well Casing /�a <br /> Domestic/public Driven Gauge of Casing 1406-4- <br /> Irrigation <br /> 406,4:Irrigation Gravel Pack Depth of Grout Seal -T-- — o <br /> Cathodic Protection Rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Ivo 4c- Ida m P <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 accordant <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 C L FOR GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Ce --P— DATE:-/G 7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I — <br /> APPLICATION ACCEPTED BY QO V DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY \C�`1 DATE 2 C <br /> H 1426 Rev. 12-771/78 2M <br />