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AI I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONST9UCTION OR PUMP PERMIT Date Issued,-7-27 ;? <br /> This Permit Ex fires 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 />,caquin County- Ordinance N,b. 1862 and the Rules and Regulations of the San. Joaquin Local -Health <br /> District. <br /> EXACT STREET ,ADDRESS <br /> 1 l i CITY/TOWN " (� <br /> Owner' s Name //,-5Phone 9 a — 7% <br /> Address 5101 Cit <br /> Contractor's NameLicense# Phone / <br /> IS CERTIFICATE OF WORKMA(V S COMPENSATI0N1 NSURAMCE ON FILE WITH SJLHD? YES NO <br /> 3 � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ , <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK )' SEWER LINES PIT PRIVY <br /> SEWAGE DISPO IELDc2ffi-' CESSPOOL/SEEPAGE PIT OTHER [c &Z-/,0 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL 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 i <br /> Domestic/public Driven Gauge of Casing L1) <br /> Irrigation _Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal �' Other Other Information �� ---1, <br /> Geophysical Surface_ Seal Installed by: �Z,`a J <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump H.P. <br /> PUMP -REPLACEMENT: ❑State Work Done ! <br /> PUMP REPAIR: (--]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe M,aterial and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance. <br /> Frith San Joaquin County Ordinancels, State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or 1'icensed 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 FOR A GRO INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �- TITLE: DATE: <br /> DR W PLOT N ON REVERSE DE <br /> FOR DEP RTMENT USE ONLY <br />)RASE I ? s <br /> PPS'-LiCATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT I-NSPECTION PHASE III FINAL INSPECTION <br />;NSPECTION BY DATE 'i — 7 INSPECTION BY DATE ... <br /> 3 <br />;U 1 nI)c r)— 1 n -7-7 <br />