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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r J , CA 95205 Permit No. <br /> IFQ FAQ FICE USE: � 1601 E. Hazelton Ave. , Stockton <br /> Telephone: (209) 466-6781 <br /> -/ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-.A - <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 /> -Joaquin County Ordinance No. 1862 - and the Rules and Regulationsofof the San Joaquin Local Health <br /> District. r / � - (�/ - (l6 —Olt, I <br /> two:. CITY/TOWN <br /> EXACT STREET. ADDRESS iov ��,�,� ,: ea! �1r en S r�,�e d.4AC,(�-.- <br /> Owner' s Name 2tY&12 A6r ! / Phone <br /> Address (a City ei r <br /> , Contractor' s Name License# ef3?L ''Phone ✓�� �� <br /> IS CERTIFICATE OF WORK"IAN'S C 1PE"1SATI0'1 INSORA1110E ON FILE WITH SJLHD? YES .k NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR R1 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> CESSPOOL <br /> SEWAGE DISPOSAL FIELD SEEPAGE PIT OTHER <br /> / - <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation FTI <br /> -Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X _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. 2 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ]State Work .Donedo ' <br /> t _4o rWst <br /> s <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 . " i <br />. . I WILL CAL FOR A GROUT INSPECTION P TO GROUTING AND A FINAL INSPECTION. <br /> 1 <br /> SIGNS ' i- _ITLE : DATE: <br /> DR W PLOT PL N REVERSE SIDE <br /> FDR DEPA TMENT USE ONLY <br /> PHASE12 �/77 <br /> APPLICATION ACCEPTED BY DATE b/ <br /> ADDITIONAL COMMENTS : <br /> PHASE I GROUT INSPECTION I PHASE III FINAL INSPECTION` <br /> INSPECTION BY DATE INSPECTION BY DATE io <br /> I.H 1Q 71; Rav A/7. � 5/ 9f �i <br />