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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFFICE USE: �.. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. I d <br /> Telephone: (209) 465-6781 Date Issued r7-/6`-� ' <br /> r' APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> PF RMIT <br /> (Complete In <br /> Application is hereby made to the San Joaquin Loc eal�1�8t for a permit to construct <br />;and/or install the work herein described. This applicaMn �s ma a in compliance with San <br /> Joaquin-County Ordinance No. 1862 acid the Rules and 90WAO&F6DSan Joaquin Local Health <br /> District. rT <br /> EXACT STREET ADDRESS / CITY/TOWN + � - <br /> Owner's Name EM bZ,4 <br /> Phone Y <br /> City.- <br /> Address <br /> Contractor's Name License y ZUZ Phone <br /> :IS CERTIFICATE OF WORKMAN'S COMPENSATIOM INS" ?•irr ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELLE4 DEEPEN ❑ RECONDITION DESTRUCTION[n <br /> WELL CHLO INATIONj3 WELL ABANDONMENT SMP REPLACE ENT <br /> EJ <br /> PUMP INSTALLATION G3 "PUMP REPAIR❑ PU <br /> / PIT PRIVY a <br /> _ SEPTIC TANK b SEWER LINES .. . <br /> DISTANCE TO NEAREST. }� <br /> PROPERTY SEWAGE ILINL6�if RIVAT 0 ESTIC WELLSEc PUBLIC'DOMESTIC P�GE -FIT RWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS e <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> kDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> 'Other Other Other Information <br /> 1---77--Geophysical' Surface Seal Insta ed b <br /> vPUMP INSTALLATION: Contractor a)0�0 Al <br /> Type of Pump H. . <br /> I'PUMP REPLACEMENT: _,7]State Work Done <br /> RUMP -qEPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material an rote ure <br /> 1I 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 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 CAL1, FOR AOUT-)INVIE,6101N PRIOR TO GROUTING AND A FINAL INSPECTION. ti <br /> t <br /> ISIGNEDTITLE: DATE: <br /> D L N ON REVERSU S I DE <br /> F R LjEJ IdZIMENT USE ONLY <br /> PHASE I DATE 7UI 7 <br /> -APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASEI GROUT INSPECTION ' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE la�'�y '' INSPECTION BY ems... DATE ;77c <br /> FS-I ld 99 Rev Q/7S2 ., _.._ - - <br /> 9/78" <br />