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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1 1601 E. Hazelton Ave. , -Stockton,``CA 95205 Permit No. 7S- S7 <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued <br /> 15� (Complete In Tri-pl'iacate)' r � <br /> W <br /> ,Application is hereby made to the San Joaquin Local Health District for a permit =onstruct <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. �,��:'� los-t_-z-- l3 <br /> EXACT STREET ADDRESS LD` t •.-f ITY./TOWN �c�,I�►� _ <br /> Owner's Name Phoneglo <br /> Address 4 0rtr+-r L. Y City&2A rx.s <br /> 'Contractor's Name_ , ,/�r� Li cense L Phone <br /> T5 CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL E4 DEEPEN ❑ RECONDITION Q DESTRUCTION( <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER C3 <br /> PUMP INSTALLATION C1 PUMP REPAIR❑. - PUMP REPLACEMENT Q <br /> bISTANCE TO NEAREST: SEPTIC TAN �+ SEWER LINES-<o4 PIT PRIVY <br /> SEWAGE DISPOSIELDCESSPOOL/SEEPAGE PIT OTHER--- <br /> E/a <br /> _ PROPERTY LIN4PRIVATr70RESTIC WELL, PUBLIC DOMESTIC. WELL <br /> INTENDED USE TYPE OF WELL CON5TRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> Domestic/private Drilled Dia, of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal UU <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: , "Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: '❑State Work Done <br /> PUMP REPAIR: QState 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 /> P 'I certify that in the performance of the work for which ' 's permit is issued, I shall <br /> not employ any person in such manner as to become subje _ to Workman's Compensation <br /> laws of California." ' <br /> I WILL CALL-FOR A SROUZ INSP ION PRIOR TO GROUTING AND A'FINAL INSPECTION. <br /> SIGNEDi <br /> TITLE: e,av DATE: <br /> P-M71W ON REVERE IDE <br /> R <br /> PHADEPARTMENT USE ONLY <br /> ...._- <br /> PHASE I <br /> APPLICATION ACCEPTED BY od e -DATE 32 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II F L INSPECTION <br />'INSPECTION BY DATE INSPECTION BY DATE --J~Z; <br /> ESI 14 26 Rev. 9/7A . . .... QI7R 9M <br />