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Co 004,i SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.' -/1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 7 <br /> This Permit Expires 1 Year From Date Issued <br /> ` (Complete In Triplicate <br /> IApplication 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 /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the �San. Joaq�in Local Health <br /> rDistrict. ` <br /> -CITY/TOWN <br /> EXACT .STREET ADDRESS LP 3=1 <br /> i Owner' s Name !tom a 6 J'� �,�� Phone <br /> Address ' �; Ci ty. <br />' Contractor' s Name �,. - V License# /fJ7-).Y' �- ` <br /> Phone o 4 a- <br /> IS CERTIFICATE OF WORKMAN'S CO111PE SA O"3 INSURA"•SCE ON _FILE WITH SJLHD? YES k NO _ <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT N <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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c� <br /> Industrial Cable Tool Dia. of Well Excavation s <br /> i >_- Domestic/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 /> Disposal Other Other Information <br /> i Geophysical Surface Seal Instal ed b <br /> "PUMP INSTALLATION: Contractor ,� ? <br /> t .. Type 6f Pump_ C2 Ex dI A), /a dam, H. <br /> "UMP REPLACEMENT: ( State Work Done �; ,�Q alb ,� ...�. 1�i►J �� �✓ - <br /> ' PUMP REPAIR: p'State Work Done <br /> rDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I haveprepared 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 ownerlor 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 became subject to Workman's Compensation <br /> laws of California." <br /> [ I WILL CALL. FOR A GROUT INSP C O PRS TO GROUTING -AND A,FINAL INSPECTION. <br /> '=SIGNED t�e�k/ ,• _ ,, TITLE: ' DATE: <br /> R W° T PL N ON REVERSE SIDE) s` <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> `APPLICATION ACCEPTED BY + DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE -III,,.FIN8L INSPECTIONFA <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F _ <br /> y ^7 <br />