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SAN JOAQUIN ,L•OCAL HEALTH DISTRICT <br /> FFICE USE 1601 E. Hazelton Ave.,, Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 , . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This. Permit Expires 1 Year From Date- Issued' <br /> Complete .In Triplicate <br /> Application is hereby made J the San Joaquin Local Health District for a <br /> perm7t to construct <br /> and/or install the work here in- 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 6 A211 <br /> CITY/TOWN <br /> F <br /> Owner's Name Phone�q <br /> Addr.ess- <br /> o city, 1..yB <br /> Contractor's Name 1012AJE0 A 3 ZJC1,1 Licenset_,;�7?Z& Phone_ /j <br /> IS CERTIFICATE OF WOP.KIIAN'S C0MPENSATI0i1 Ii1SURA1,1 E ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTICI TANK_+SEWER LINES_j4'_{- PIT PRIVY — <br /> --- <br /> SEWAGERDISPOSAL FIELQQ,,�� CESSPOOL/S PAGE PIT OTHER <br /> PROPERTY LIN k/afPRIVATE�DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia. of We-11 Excavation /2 Y <br /> Domestic/private Drilled Dia. of Well Casing x <br /> Domestic/public DrivenGauge of Casing <br /> do- <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> ______Disposal _ Other _--� _ . <br /> . Other Information_ < ,&Al 4= fa... <br /> Geophysical _ Surface Seal Installed by: elljZ1 -- <br /> PUMP. INSTALLATION: Contractor._ <br /> Type of Pump 4^- H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: CDS:tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> . x <br /> Describe Material and Procedure <br /> r` <br /> I heretbycertify 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 ce'rtifylthat 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 GROUT _AP?0,,TI99AOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED } <br /> TITLE: DATE: <br /> R W PL T PL N ON REVE S IDE <br /> PHASE I LY <br /> FOR -DEPARTMENT USE ON <br /> APPL I-CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II F NAL INSPECT116N1 01 <br /> E� <br /> INSPECTION BY TE f; 78 INSPECTION BY DATE 7-,.3 70 <br /> ia9� Qn.! ,x_77 - <br />