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SAN JOAQUIN, LOCAL HEALTH DISCRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No. - M <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-12 <br /> This Permit Expires l Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San JoaquinLocalHealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br />,oaauin County Ordinance 1o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS NoqqAA � ��� yl�e� �P44' ( AC CITY/TOWN <br /> Owner's Name kOTA Phone L/7t" �. <br /> Address C/ �x t �3� ��J/Ji�T�//T/ ° �5���� City _r <br /> Contractor' s Name peoftl Li cense# 19 V 16 Phone 7/ 'y7> <br /> IS CERTIFICATE OF WO KitAN'S CO"r1PEJ ATIO J JSURA"!CE ON FILE WITH S�L D? YES IJO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION ❑ DESTRUCTIONX <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR O PUMP REPLACEMENT 0 <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. <br /> PUMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth/'/ _ <br /> Describe Mate rsri"a�androce ure � U At 4-, L- <br /> t"I-rir �iJ� plri 6 ZA,., ti C <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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. �+ <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPZD Yk. DAT ( 1� <br /> ADDITIONAL COMMEN <br /> PHASE II PECTION PHASE I I FINA INSPE <br /> INSPECTION BY DATE INSPECTION BY DATE I►.12.191 <br /> EH 1426 Rev. 12-77 1/78 2M <br />