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p <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> QR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9?_ZZ 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G2 _ 7 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS L-�4-�30 \M�AC_1 , CITY/TOWN ro <br /> Owner's Mame Phone V`3 S -- L cI 24 <br /> Address 01. <br /> Contractor' s Name s License# � ')� p Phone �--- ;3 4- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IINSURANCE ON FILE WITH SJLHD? YES IN _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [] RECONDITION C] DESTRUCTIONE3 <br /> WELL CHL INATION Q/ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION W PUMP REPAIR❑ PUMP REPLACEMENT [J WO <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 <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1_Domestic/private Drilled Dia. of Well Casing 1 _� <br /> Domestic/public Driven Gauge of Casing S e U62C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 1 urface Seal Installed by: <br /> PUMP INSTALLATION: Contractor L.r — ' r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State 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 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 Af;MUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �y TITLE: DATE: <br /> DRAW PLOT PL N ON REVERS IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATES <br /> ADDITIONAL COMMENTS:SE II GROUT INSPECTION PHASE III FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATCTION <br />.EH 7 426 Rav 19-77 _ � /78 2M 3 <br />