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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 29, <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z� 700 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT the 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 /> Joaquin County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. a Lt)7 LI-7 <br /> EXACT STREET ADDRESS ARXHUZ AD wEaz .rwl! .,- CITY/TOWN ca�� <br /> Owner's Name U: ��sh��� CDA&*60ZE —M�L&4'MA� Phone 2-(ti7127 <br /> Address '4/i Sl�/,,7TE"G�UEr2 R� �-v�t.QCK- City <br /> Contractor's NameCALMMMM License ,Z//„ 2 Phone <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD"? YES I$C "JO <br /> TYPE OF WORK (Check) : NEW WELL$4 DEEPEN ❑ RECONDITION DESTRUCTIONED ==WELL CHLORINATION O WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION El PUMP REPAIRED PUMP REPLACEMENT [I N <br /> DISTANCE TO NEAREST: SEPTIC TANK LIW SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD`D I 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 //41 <br /> _Domestic/private _ Drilled Dia. of Well Casing__.,� <br /> Domestic/public Driven Gauge of Casing pyG /60 <br /> Irrigation __ [ Gravel Pack Depth of Grout Seal 6V <br /> Cathodic Protection _Rotary Type of Grout BEAZ-j-pyf7jg <br /> Disposal Other Other Information <br /> Geophysical Surface Seal 1 n s ta 11 ed by: SL, <br /> u e w ►r <br /> PUMP INSTALLATION: Contractor S_r W1.SLAW pgJte -7g.--qZlf <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Q 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 accordance <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 FOY A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_�16 17t <br /> ADDITIONAL COMMENTS: <br /> PH E II GROUT INSPECTION PHASE IIJ FINAL INSPECTION <br /> ZINSPECTION <br /> INSPECTION BY _ DATE �— ll,-"1� INSPECTION BY 4� �t� ATE 6 '7f <br /> EH 1426 R -7 � 78 2M <br />