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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FF>:CE U5E: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permi t No. 7 q - g,1,5 <br /> Telephone: (209) 466-6781 <br /> In APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue !5,/-5-7!2 <br /> This Permit Ex ires 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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District'. ,p.4!"ILE /r! O c OAW 07"' ;F�e7 <br /> EXACT STREET ADDRESS SSD/ 6- e9,-- , 1—Y, `.,VS )F--D CITY/TOWN_.10 <br /> Owner's Name . Z,,-;1->1 Q/ti - C-o, IAIC Gsu_vf v` Phone L1-- 'f <br /> Address 12�0o ✓J /��' �4 V� -- Cit0 9S <br /> Contractor's Name C1, --5o 1 tit fF4e- _-Dr/i., Me4 Li cense#3a2o9f Z_,Phone -7�— 33?:' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES�� IJO <br /> TYPE OF WORK (Check) : NEW WELL.. DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [) <br /> DISTANCE TO NEAREST: SEPTIC TANK Do SEWER LINES /®o-�-- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE F`kIVATE DOMESTIC WELL—=PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _X Industrial Cable Tool Dia. of Well Excavation 1 f + sT/ <br /> Domestic/private Drilled Dia. of Well Casing /0 <br /> Domestic/public Driven Gauge of Casing /0 <br /> Irrigation Gravel Pack Depth of Grout Seal Is-co <br /> Cathodic Protection Rotary Type of Grout + 6","7-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: In <br /> DATE: <br /> (DRAW PLT L N ON REV RSE SIDE <br /> / <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 14, <br /> EH 1426 Rev. 12-77 <br />