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1Iy- <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.'7,f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued aB' <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate v _ <br /> Application is hereby made to the San Joaquin Local Health District for ,a permit to constrr0 ''"-1 <br /> and/or install the work herein described. This application is made in compliance with San <br />,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS - ti Pet � '� ®' I4 Y/TOWN <br /> Owner' s Name 1'i Phone <br /> / <br /> Address � s� 1E'�'- � /lam` ., . City.. <br /> Contractor <br /> Li cense#4G A41-/9 <br /> Contractor's Name ��z-'r"� M ¢'S `�-3`7...� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES �� NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ • WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR(--] PUMP REPLACEMENT <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 1:7.. -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- 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor i" <br /> Type of H. . <br /> PUMP REPLACEMENT: []State Work D �' OR <br /> ' <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 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 PL N' ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I R1, <br /> APPLICATION ACCEPTED BY �p,�y, �,� <br /> DATE <br /> ADDITIONAL COMMENTS: PQnnit Jo dtopih wa;11 *V6- '.aAvbiz 161zIndd & drihtL— <br /> PHASE II GROUT INSPECTION PHAII J FJAAAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE,�%Z��fz <br /> FH 1429 Rpv- 12-77 1 /78 M <br />