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ZOS— l3o—�3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />_EOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 3 Z <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip irate ' <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 /> 'oaQuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ob 'UA// *Crw <br /> EXACT STREET ADDRESS E&AL e 'a/ A ZLexo- CITY/TOWN e6kcq Zed <br /> Owner' s Name J o bJ Phone <br /> Address ©A d City a .✓ <br /> Contractor's Name Li censeD 65-7-,6-L Phone <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATIO'N IINSURANCE ON FILE WITH SJLHD? YES Zr NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER � <br /> PUMP INSTALLATION ❑ PUMP REPAIROR--" PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK 4±. e-_ SEWER LINES *#&e—PIT PRIVY <br /> SEWAGE DISPOSAL FIELD IPe N{ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINUr PRIVATE 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 /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor v w c- - <br /> Type of Pump W.P. (n <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: MState Work Done 62y e C r <br /> DESTRUCTION OF WELL: Well Diameter y Approximate Depth <br /> Describe Material and Pro ce 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 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 GROUT INSPECTION PRIOR TO GROUTING AND a FINAL INSPECTION. <br /> SIGNED Alk TITLE: DATE: <br /> - (DRAW PLOT PLTN ON REV 4-6f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATES $ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> t <br /> EH 1426 Rai_ .12-77 -1. /78 2M - <br />