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SAN JOA <br /> QUIN, LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E, Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Telephone: (209) 466-6781 <br /> -APPLICATION FOR"WELL CONSTRUCTION OR PUMP PERMIT t Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete 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 'applicatfon 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 V , CITY/TOT <br /> d � r <br /> Owner's- Name MA Ac Phone <br /> Address ! <br /> city <br /> Contractor's Name 1?'!License Phone <br /> IS CERTIFICATE OF Wn X164 C0I7PENSATION INSURAKE ON FILE WITH SJLHD? YES t/ 1.40 <br /> TYPE OF WORK (Check) : NEW WELLW DEEPEN Q RECONDITION DESTRUCTIONS] <br /> WELL CHLORINATION Q,,e WELL ABANDONMENT 0 OTHER( _. _ __-- <br /> PUMP INSTALLATION ® PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK_W SEWER LINES ' SPIT PRIVY �' <br /> SEWAGE -DISPOSAL1FIELD o f CESSPOOL/SEEPAG PITk_ OTHER C <br /> PROPERTY LINE,6 PRIVATE DOMESTIC WELL X PUBLIC DOMESTIC WELL �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation f -` <br /> kZ 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 Rotaryf Type of Grout / + - <br /> �bisposal Other..; Other Information <br /> Geophysical w Surface _Seal . Instal ed .by:kr -A- <br /> PPUMPINSTALLATION: Contractor �- <br /> Type of Pump" H.P. {y/F <br /> PUMP3REPLACEMENT: .Q State Work Done <br /> PUMP REPAIR: Q State�Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> thereby 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 l <br /> Health District. i 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 Ca1ilfornia." <br /> 1 WILL CALL: FOR A GROUT INSPECTION PRIOR TO GROUTING AND .A FINAL INSPECTION. <br /> SIGNED >�.I TITLE: p DATE: - - <br /> V Cop, I-(DRAW PLOT PLVN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY i <br /> PHASE i' 3 <br /> APPLICATION ACCEPTED Be DATE/Aw Z�v <br /> ADDITIONAL COMMENTS: WT .Gw <br /> PHASE II GROUT INSPE IO PHASE III FIKAL INSPECTION <br /> INSPECTION BY ` " DATE og- ,INSPECTION BY DATE,y 7 <br />-EH 1426---- Rev_ 12-77 _ 1 17.8. --2M <br />