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SAN JOAQUIN LOCAL HEALTH UISIRICI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 ,- elmit No. <br /> -`, Telephone: (209) 466-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 7P <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 ;2 f CITY/TOWN <br /> Phone <br /> Owner's Name <3=. 2 <br /> Address 2/2 C Aur.."M City .�.��. . <br /> Contractor' s Name wd LicenseF:?�_?[/q - Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I11110,11R NCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN) I RECONDITION 0 DESTRUCTION( � <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT [ � <br /> m <br /> DISTANCE TO NEAREST: SEPTIC- TANK.Sd 1-{- SEWER LINEPIT PRIVY — <br /> SEWAGE DISPOSAL FIELDSp1t CC S�L/SEEPAGE PIT OTHER --- <br /> PROPERTY LINVC?14PRIVATE DOMESTIC WELLS" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavationes rrZAI F k <br /> Domestic/private Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing &—L--/—� ��,��,�f�l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformationLb.r <br /> Geophysical Surface Seal Installs by. --- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 FOR A GROUTOINAPECTIV PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE:1Q _ <br /> (DRAW PLOT PLAN ON REVERGE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r11d179 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .,r , DATE_$ P 31 Ag <br /> EH 1426 Re 2-77 �a5 1/7 8 2M <br />