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r� � •=>I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LFOR -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued��� 7 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET `ADDRESS c! �� - � ° CITY/TOWNc <br /> Owner's Name y� _ ,,,, .3, Phone <br /> Address 701! __r AceJy4t W Ci ty �� <br /> Contractor's Name -V e, •- r..4 C,a' Li cense#/13 921"Phone <br /> IS CERTIFICATE OF WORKMAN'S CO . E SATIO'N I'NSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CES— SQL/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 Wehl Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ,c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor j a w ,°r c�t, <br /> Type of Pump H.P. G a <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QState Work Done tAp/sCt �l�r�r . /e��F �•c r ' 144� <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 INSPEQTIOK RRI, TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED` ITLE: s DATE: <br /> W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATES -�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y <br /> EH - 1/78 .2 .- <br />