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Z)AN-JUAQU1IV LUL.AL,MtHLIH UiJIKi11 <br /> FFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No. 7 <br /> Telephone: (209) 466-6781 a <br /> '4. 1 1i Date Issued //—/X-'-.;9V'- { <br /> 40 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit 'Ex ares 1 Year From Date Issued <br /> 'Coniplete In Tripl'icafe i <br /> Application is hereby made to the San Joaquin Local Health District fore permit to construct . <br /> acid/or install the work herein described.. This application is .made in compliance with San <br /> �oaQ �n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr'ct. f <br /> EXACT' STREET ADDRESS 5e1 !i � CITY/TOWN 13 <br /> Owner's Name le7 Z UV Phone <br /> Address City <br /> Contractor's Name s t /License X e phone 9a — T <br /> IS CERTIFICATE OF- WORKMAN'S COMPENSATION INSURAN E,,ON FILE WITH SJLHD? , YES N0 <br />' TYPE OF WORK (Check) : NEW WELL P__­"DEE.PEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER 0 - <br /> if PUMP INSTALLATION 14PUMP REPAIR❑ PUMP REPLACEMENT <br />` DISTA•NCE' TO NEAREST: SEPTIC TANKA06 EWER LINES"IT PRIVY <br /> SEWAGE DISPOSAL FI,E�LD �� CESSPOOL/SEEPAGE PIT �'fJ /OTHER '�" OS <br /> PROPERTY LINA; }?iVATE DOMESTIC WELLX .4_- PUBL C DOMESTIC WELL <br /> INTENDED- USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial: Cable Taol Dia. of Well Excavation <br /> 4---Domestic/private milled Dia. of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigationavel Pack Depth of Grout Seal <br /> Cathodic -Protection Rotary Type of Grout 1� <br /> Disposal ! Other Other Information <br /> Geophysical Surface Seal Installed b <br />( PUMP INSTALLATION: Contractor 1;?,1 <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 Proce ure <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 j-S `is.Sued, I shall <br /> not employ any person i-n-su.ch .manner as._to become,.s-ubject to Workman' s-Compensation <br /> laws' o•f-Cal ifornia." _ <br /> A- <br /> kI WILL CALL F A GR T I NSPECTI'ON"P'RI'OR"TO-GROUTING=ANDA FINAL INSPECTION: '� . <br /> NSIGNEDL k TITLE; � �Sj DATE: <br /> DRAW PLOT PLAN ON REV RS SIDE <br /> FOR D PAR MENT USj NLY ti <br /> IPHASE I x <br /> APPLICATION ACCEPTED BY A # DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ,'INSPECTION BY DATE INSPECTION BY� DATE\ <br />