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e SAN JOAQUIN LOCALHEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. Zf/u11.3 <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 /> 4-0 <br /> well �Jt (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. A4413'hW <br /> EXACT STREET ADDRESS / `i A4,Icw.r Sam Annf '� art CITY/TOWN <br /> Owner's Name 14- ids-"J:a Phone 131 --39 sw <br /> Address / J� =Agal.��r��C1 eZ�► City S <br /> Contractor's Name �a Li cense#/!3-7Yo---Rhone �ff= 3.- —74 7�. <br /> IS CERTIFICATE OF WORKMAN'S CO". ENSATIO'N INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0ZO <br /> PUMP INSTALLATION ❑ PUMP REPAIRRU PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 H.P. t&I) <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: (State Work Done40 Ozr it <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 accordanc <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 INSPEWOA PRIOR, TO GR TING AND A FINAL INSPECTION. <br /> SIGNED E: �i ..i"-- DATE: <br /> UKAI, pInT PLANUMREVERSE SI E <br /> PHASE I FOR DEPARTMENT SynONLY <br /> APPLICATION ACCEPTED BY t'c� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1/78 2M <br />