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SAN JOAQUiN LOCAL HEALTH DISTRICT <br />___FOR QFFI&E USE: 1601 E. Hazelton Ave.�,. Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> T APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7,Z - <br /> This Permit Ex ires 1 Year From Qate Issued , <br /> s <br /> (Complete In Triplicate) � 42W. ,. <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. ' Thi's 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. r--- <br /> EXACT STREET ADDRESS CITY/TOWN /Gc_�� tr• <br /> Owner's Name Phone <br /> Address -- SGt -� Ci ty—. <br /> f.. -� Ln <br /> Contractors Name , ,v License# Phone <br /> TS CERTIFICATE 0 t f',K�1Ai 'vS "�PENSATIO ! IESSURAINCE ON FILE KEITH SJLHD? YES Il0 r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTIONja <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION,K PUMP REPAIR❑ PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC TANK OSEWER LIVES �SD PIT PRIVY <br /> SEWAGE DISPO AL MELD , LO CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEAVPRIVATE DOMESTIC WELL -4E L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i <br /> Industrial Cable Tool Dia. of Well Excavation ,Q" <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing>T' .. 44e. <br /> Irrigation Gravel Pack Depth of Grout;'Seal� 416 <br /> Cathodic Protection Rotary Type of Grout ems. �I -t- <br /> Disposal . Other_ Other Information <br /> Geophysical Surface Seal Installed by: ,mew <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump P. <br /> PUMP REPLACEMENT: State Work Done 06 Zajag,1,1 <br /> PUMP REPAIR: Q State Work Done I <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 iss e , I shall <br /> not employ any person in such manner as to become subject to Workman's Com cation <br /> laws of California." <br /> I WILL CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ' DATE: <br /> --- ___(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY_ TE 3 a <br /> r . .. . .. .. 1,770 7M <br />