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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 9—a2 9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedz/-.3-7- <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate)- <br /> Application <br /> riplicate •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 />,'oau.>;n County Ordinance No. 1862 and the Rules and Regulations` of the San Joaquin Local Health <br /> District. <br /> EXACT STREET,ADDRESS4, CITY/TOW <br /> Owner's Name 1,Z e Phone 9ULa& 0- _ <br /> Address 24) City_ <br /> Contractor's 'Name Q.�. � �, /� -- -_ _ Licensege,,?Z J9 Phone A �.�.►�1� <br /> IS CERTIFICATE OF WORKHAN'S CTIPENSATIOiN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK -(,Check) : .,NEW WELL❑ -,DEEPEN ❑ RECONDITION Q ' DESTRUCTION❑ <br /> `�"• ~`CwtW-CH-LORINATION ❑ WELL ABANDONMENT ❑: OTHER ❑ <br /> PUMP INSTALLATION [3---PQ <br /> _MLREPAI R CK PUMP REPLACEMENTLL❑_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE:, DISROSAL_ FI,EL.D ,'s CESSPOOL/SEEPAGE P.IT -----OTHER <br /> 'PROPERTY LINE -. PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 'OF WELL 44 1 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�� ��n Type of Grout <br /> Disposal Other Other.' Information <br /> Geophysical Surface Seal . Installed by: ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump J.P. <br /> PUMP REPLACEMENT: _ r]State Work Done <br /> PUMP REPAIR: RIState Work Done ` ---. ---,J <br /> .. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> --__.Des.cribe Material and Procedure <br /> I hereby certify that I ,have prepared this application and that the work will be done in accord ce' <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc I . <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 CAL R Z G6QUT JASPECTION PRIOR TO GROUTING AND A FIN L, INSPECTION. <br /> SIGNED �; '`,`; }` TITLE: DATE: <br /> 4 <br /> (DRKW PLOT; 'RL N ON REVERSE-SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY� �,� �,. . ' ' ��•ea-� DATE ,3- 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /--Z (Zf L <br />