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I` SAN JOAQUIN LbCAL HEALTH DISTRICT <br />� 'F E USF: ! 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> � J7 <br /> s / Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued.-/�7/ <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �`(� e r CITY/TOWN a� <br /> �M Phone y0,. <br /> Owner' s Name ' E :5 <br /> Address. City <br /> Contractor's Name <br /> �Litcense# a Phone <br /> IS CERTIFICATE OF WORKMAN'S C MPENS TMN INSURANCE ON FILE WITH SJLHD? YES V-00 NO <br /> TYPE OF WORK (Check) : NEW WELL? DEEPEN ❑ RECONDITION [3 DESTRUCTION[j <br /> WELL CHL RI <br /> WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION. PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN Kl2 2 SEWER LINESAba_ PIT PRIVYAIA., gV�i� (A <br /> SEWAGE DISPOSAL FIELD f CESSPOOL/SEEPAGE. — OTHER --'' <br /> PROPERTY LIN °PRIVA E DOMESTIC WELL A&A&PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 611 <br /> Industrial Cable Tool Dia. of Well Excava <br /> Dia. of Well Casingtion <br /> �_ .�/ ': <br />� Domestic/private Drilled <br /> Domestic/public ' Driven - Gauge of Casing { <br /> Irrigation Gravel Pack Depth of Grout Seal e <br /> Cathodic Protect ion =,Rotary Type of Grout <br /> Dis osal Other Other Information <br /> Disposal <br /> Geophysical [I[ Surface Seal Installed by, <br />'-PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �w <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: State Work Done �- <br />{ DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ., <br /> I�S <br /> I hereby certify that Ilhave prepared this application and that the work will be done in accordancE <br /> with San Joaquin Countyl�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 AA1 <br /> laws of California. `' <br /> I WILL CA OR A GROUTI�!INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNS <br /> 'M TITLE: DATE:-3/ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> k7 FO R PARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY, <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I P I N PHASE III FINAL INSP CTION <br /> p INSPECTION BY IN: DATE INSPECTION BY� DATE/z12- 7—Z <br /> AFH 3a7h RaU_ 39_77 �:�: <br /> i 7 8 2M, <br />