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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.--7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued X17 ' <br /> This Permit Expires 1 Year From Date Issued <br /> f <br /> Complete In Triplicate) <br /> Application is hereby made to the San Joaquih-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 CITY/TOWN—AC-4/`Iv <br /> Owner's Name <br /> CVs Phone_ �_ �rl�f.� <br /> Address Ci ty6 c.4-lan <br /> Contractor`s Name LicenseesL�y Phone - <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK {Check.) NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION EDWELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Ej <br /> CA <br /> DISTANCE TO NEAREST: SEPTIC TANKED r-F SEWER LINE p �-{ PI7 PRIVY � <br /> SEWAGE DISPOSAkrFIEL-D CESSPOOL/SEEPAGE PI —OTHER <br /> PROPERTY LINE- PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation_ <br /> Domestic/private Drilled Dia. of Well Casing -- <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack w Depth of Grout Seal UU <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Installed b uri <br /> PUMP INSTALLATION: 'Contractor- ' <br /> Type of Pump s 2 �'� H.P. - <br /> Z_- <br /> PUMP <br /> .P. Z_-PUMP REPLACEMENT: ❑State Work Done „ <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF W.ELL:. : Well Diameter Approximate Depth - �- - - - <br /> Describe MatJ51 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 CA OR A GR T INSP TJJDN MR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ,r <br /> D PL T PL N ON REVERSQ SIDE <br /> FOR,,7DEPARTMENT USE ONLY <br /> PHASE I ti 1 <br /> APPLICATION ACCEPTED BY DATE <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BYE DATE �117 <br />:H 1426 Rev_ 1?_77 R rA' -, Jae �.. <br />