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SAN JOAQUINy)LOCALOHEALTH DISTRICT <br /> FOR QFFICE USE: 1601 E. Hazel ton, Avek.1- Stockton, CA 95205 Permit No. <br /> Telephone-,-,: (209) 466-,6781 <br /> 6&�71 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Per,[Q Lt�,Expirs._] :YeArFrom Date L5 sued <br /> I etp,IP .Triplicate <br /> Application is hereby made to the San Joaqui6' Local,iHealth,--,Df'strict for :a permi t,-Eto,­construct W <br /> and/oi,! 'ihs-taflT�'I'tlie'-'�wcii^k 'hre�ie!'n &escri b�d i!;r This.appl tcatidni Js -made.:-:in -c-ompl-J:ance 0th Sari <br /> tfieRul6s-mandi.Regulationrs of the =.SanJoaqui,n,> Lotal: Heal,th <br /> District. <br /> z C <br /> EXACT STRE`E_"_'A664tS'S <br /> 7.S2 W <br /> WN <br /> Phone /;, //Oe <br /> Owner' s Name cz. dCq,^C F2 5Z <br /> V <br /> Address <br /> Contractor' s Name <br /> Li cense# ,q fg Phone.d:y -,4Mj1 <br /> IS CERTIFICATE OF ;;;9Z COMIPENSATION INSURAINCE ON FILE WITH SJLHD? Y E S NO fi <br /> TYPE OF WOR.-K (Check) : NEW WELL M DEEPEN 0 RECONDITION C] DESTRUCTIONC2 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION, PUMP REPAIR 0 PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: . SEPTIC- TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT OTHER <br /> PROPERTY LINE -. 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 /> Irrigation 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 <br /> Type of Pump �;19 R.P. 7 <br /> PUMP REPLACEMENT: a State Work Done <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL.: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I haVe prepared this application and that the work will be done in accordancq. <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 iss I shall <br /> not employ any person in such manner as to become subject to Workman's Com tion <br /> laws of California. " <br /> I WILL CALL FOR A: GROUT INSPECTION PRIOR TO GROUTING AND A .FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> CZ (DRAW- PLOT -,PLAN ON REVERSE SIDE) <br /> R DEPAR USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT' ED 'BY DATE 4- <br /> -I - <br /> ADDITIONAL COMMENTS . . <br /> PHASE II. GROUT; INSPECTION <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE , <br /> EH� 2M <br />