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SAN JOAQUIN ,LOCAL,.HEALTH DISTRICT <br />__E_OR OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton,.-CA 95205 Permit No. 7�f/moo <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued����7$r <br /> This Permit Expires I 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 />.'oaauin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS u1 _ CITY/,TOWN <br /> _ 4 <br /> Owner' s Name Phone %!X3 7ffa <br /> - ---�' <br /> Address Jim., City Ai - <br /> Contra'ctor's' Name w License#U�6' Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"a I11_1SUR "!CE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION C3 DESTRUCTION 13 <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER 0 O <br /> ` . PUMP INSTALLATION Er PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y 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 - H.P., <br /> PUMP REPLACEMENT: Q State Work Done. <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OFmWELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> F} , <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 f <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 r ECTION PRIOR .TO' GROUTrNG AND A FINAL INSPECTION. <br /> SIGNED TITLE DATE: O <br /> (DRAW PLOT PLKN__ ON REVERSE SIDE <br /> PHASE .I FOR DEPARTMENT USE ONLY 911/7$ v l <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE J11 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br />=u marl 0-, 1 11 � 7 Q �A <br />