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/ SAN JOAQUIN ,LOCAL� HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No.7 f-2-6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued --3-7 <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 />,oarn:in County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ` CITY/TOWN X1 <br /> 1 <br /> Owner' s Name f3,LL-/ 7A1 T Phone 2d�5 <br /> Address City. <br /> Contractor' s Nameu„� License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOPJ INSURA*SCE/O PS FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN CI RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION R9-- PUMP REPAIR❑ PUMP REPLACEMENT ❑ Q <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> Al __ SEWER LINES IfV1 PIT PRIVY T 4 <br /> SEWAGE DISPOSAL FIELD a / CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE500 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia. of Well Excavation <br /> j. __-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractorf,�' rA y �� . <br /> P. <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc( <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 FOA A GROUT INSPECTION PRIOR TO GROUTING ANDA INAL INSPECTION. <br /> SIGNED ATE: <br /> ED <br /> DR W PLOT PLAN ON REV <br /> SIDE <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE I /J <br /> APPLICATION ACCEPTED BY �% DATE <br /> ADDITIONAL COMMENTS : f —A <br /> PHASE II GROUT INSPECTION PHASE IIJtINAL INSPEC <br /> pECTION BY DATE /� INSPECTION BYE DATETIO <br /> 1178_ 2M <br />