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SAN JOAQUIN LUCAL HEALTH 0151KiLI <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7�L_/d_,F-ir <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued i <br /> This. Permit Expires 1 Year From Date Issued <br /> Compl ete, I-n 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 /> �oaca��n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 4 CITY/TOWN <br /> Owner's Name Phone 2 <br /> AddressCity <br /> Contractor's Nameicense�1/ 4i d'S�Phohe L <br /> .� <br /> IS CERTIFICATE WORKMAN'S S COfi�fPEfiJSATIO"! 'IfiJSURA^SCE Ofid"FILE'WITH SJLHD?_:"'YES`-C�.r N'0� <br /> TYPE OF WORK (Check) : NEW WELL',9R-- DEEPEN'0 RECONDITION .ff; - DESTRUCTION d <br /> WELT HLI RI°NATION-❑,, WELL ABANDONMENT ID _OTHER ❑ <br /> PUMP INSTALLATION 01 PUMP REPAIR p. ► °PUMP;REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY <br /> SEWAGE,/bISPOS�ELD I CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPERTY: LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE Av= TYPE OF WELL M --� - CONSTRUCTION SPECIFICATIONS <br /> Industrial / Cable Tool Dia.%of Well Excavation ` <br /> G.-�--Domestic/private _ Drilled Diab of We11 Casing_ <br /> Domestic/publ'ic Driven _ Gauge of_Casing /0 <br /> Irrigation Gravel ,Pack'--Depth of Grout Seal <br /> Cathodic Protection . ,rotary Type of Grout - -- "} <br /> Disposal ... .FOthe'r Other Information <br /> Geophysical - Surface S e a 1 Installed by <br /> N + <br /> PUMP INSTALLATION: Contractor �..- <br /> Ty.pe- -of Pump H.P. <br /> PUMP REPLACEMENT: �JState Work Done ; <br /> PUMP REPAIR: ❑State Work Done <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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _s - ;< TITLE : DATE: rh 41) r <br /> - DR W,"PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY ° � DATE a e' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'INSP.ECTION BY DATE INSPECTION BY DATE 1(:;2- <br /> -7 <br /> LIH <br /> - -7 <br /> H 2426' Rem_ 12-77l/78., 2M <br />