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Cam /8 SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> rFICE USE: 1601 E. Hazelton- Aver , Stockton, CA 95205 Permit No. � 3 <br /> Telephone: : (209) 466.=6781 Date Issued <br /> 'APPLICATION, FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Perm.i.t 6x ires 1 Year. From Date Issued <br /> Complete In ,.Tri pl i Cate <br /> Application- is hereby rade 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 an <br /> Joaquin County Ordinance No. 1862 and the" Rules and Regulations of the San Joaquin. Local Health <br /> Di strigct. <br /> EXACT'�STREET ADDRESS 15 CITY/TOWN - <br />' Owner's Name , -r,, Q Phone <br /> City e <br /> Address �. <br /> k <br /> Contractor's Name ; ` Li cense# 13-;�Phone_ �2 <br /> I5 CERTIFICATE OF 1�ORKt1Ai `S CO+ice NSA TN I�aSURONCE ON FILE WITH SJLHD? YES eX <br /> NO <br /> TYPE- OF WORK (Check) : NEW WELL CI DEEPEN [] RECONDITION <br /> NQ DEOTHERTfO ION <br /> � <br /> WELL CHLORINATION Q WELL AB <br /> PUMP INSTALLATION P9PUMP REPAIR p PUMP REPLACEMENT Q y <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 /> )z 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 Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> . <br /> ,Type of_Pump P H.P.. <br /> — <br /> PUMP' REPLACEMENT: Q State Work Done <br /> PUMP RSR:, - [EState',Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approx mate Depth <br /> Describe Materia and Procedure <br /> i <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 Regulations of the San Joaquin Loca• <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 Wprkman' s Compensation <br /> laws of California." <br /> ' I WILL CALL FOR A GROUT INSPECZION,4PR R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: . ,gIIf' DATE: <br /> DRAPL <br /> _TPL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IP-7 <br /> APPLICATION ACCEPTED BY DATE y� <br /> f 7 . <br /> ADDITIONAL COMMENTS: <br /> P S II ROUT INSP�E �� PHASE II F NAL INSPECTIO <br /> INSPECTION BY ' - DATg INSPECTION BY DAT <br /> ., <br /> ru 1 nI)r 171,..1 9�_7 1 7 8 2M <br /> - <br />