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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 /> • / 4— Telephone: <br /> Issued � 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the SanJoaquin 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 Sari Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ��/(� � �� CITY/TOWN � ov� <br /> Owner's Name ,� � �,,� �1 � Phone�,<S,—&s,2 <br /> Address L Cityf� c� a�,' S�bS <br /> Contractor's NameLicense#?� //V Phone �j� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIm INSURArF ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHL RINATION ❑ WELL" ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> � B ?L4 <br /> DISTANCE TO NEAREST: SEPTIC TANK.- SEWER LINES,<t) 1+ PIT PRIVY <br /> SEWAGE DISPOS99L FIELD - CESSPOOL/SEEPAGE PIT OTHER — <br /> PROPERTY LINFIWIPRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ,rte <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Pvd <br /> Irrigation _Gravel Pack Depth of Grout SeaSo r <br /> Cathodic Protection _Rotary Type of Grout C-4~,c"yZ- <br /> Di sposal Other Other Information d4,, <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 1X411 Vlk ZF-r, <br /> Type of Pump J H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia 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 CfiJL FOR A GROUT INSP T N R TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE:_S <br /> kffKAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIO EPTED BY ATE <br /> ADDITIONA % COMMENTS: <br /> PHASE II GROUT INSPECT ,O PHAIII FINAL INSP CTION <br /> � DATE �NS CTION BY D E <br /> E H5 "`r.� �,c x c , C 1/78 2M_J <br />