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F <br /> • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: /1601 E. Hazelton`Ave. , Stockton, CA 95205 Permit No._7R',.// <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,3-�8� <br /> This ,Fermi t;'Ex i res• i Year. From :Date Issued <br /> Complete .In- Triplicate <br /> 1`�i �D . J1) <br />+ Application is hereby made to the San Joaquin Loc al :Healthe District for a permit. to- construct <br />, and/or jnstall the' work herei described. .This application is made in compliance w.i.th San <br /> Joanuin County-Ordi6ance 1Jo. P1862 �and the Rules and Regulations' of the San Joaquin;Local Health <br /> District. �+ 721?2�. <br /> EXACT .STREET ADDRESS ` d �- o �-2� CITY/TOWN --- <br /> Owner's Name. , �® L� -� Phone <br /> AddressD v City 04 e, <br /> Contractor' s Name Al VZ :.S^ License# �Phone <br /> IS CFRTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION � <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER� � W <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT � <br /> 3 � <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER L�NES PIT PRIVY LAS <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN VOL. RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> # INTENDED USE TYPE OF WELL 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 <br /> Cathodic' Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> k Geophysical Surface Seal Installed by: <br /> JPUMP - INSTALLATION: Contractor <br /> Type of Pump_ s',, .7. ere� H.P. <br /> , PUMP REPLACEMENT: []State Work Done <br /> , PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF_WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and' Reg0 ations of the San Joaquin Local <br /> Health District. Home ownerlor 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 inisuch manner as to become subject -to-Workman's Compensation <br /> laws of California." <br /> EI WILL CALL A. R GRO INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: <br /> DRAW PLOT PL N ON REVERSE SIDE- <br /> R DEPARTMENT USE 'ONLY <br /> RPHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: '704 <br /> PHASE II GROUT INSPECTION PRASE III F NAL IN PECTION <br /> INSPECTION BY DATE INSPECTION BY JATE <br /> Tw T[L7� Rc., 1 x_77 i/78' 2M <br />