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c �-r <br /> CEJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: vf" 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. --746- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date .Issued <br /> This Permit Ex ires� l 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: 2862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 3X27 0J .1.Ht 4-y: �s <br /> EXACT STREET ADDRESS Qom. �� �"'� 1CQ. C,�Y/TOWN <br /> Owner's Name Phone 3 G �L3 <br /> Address V11- J"7) City <br /> Contractor' s Name ! zlzt�__ License#/%o )-313 Phone <br /> A <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURANCE ON FILE WITH SJLHD? YES L-- .JO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONE] <br /> WELL CHLORINATION © . WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION ❑: PUMP REPAIRI$- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE: -. P1RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE. OF WELL �' � . i CONSTRUCTION SPECIFICATIONS <br /> IIndustrial CablekTool '. Dia. of Well Excavation i <br /> Domestic/private Drilled .....;,4.ti 4Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graved Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br />'4 Disposal Other Other Information <br /> E Geophysical _ Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> ,epi <br /> Type of Pump x H.P. <br /> PUMP, REPLACEMENT: ElState Wor0 Done <br /> PUMP REPAIR: Rstate Work, Donsr1� <br /> ��.y �� 1�- + _ <br /> DESTRUCTION OF WELL: Well Diameter, Approximate Depth <br /> Describe Material 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 licen5�ed agent' s signature certifies the following: <br /> "I certify that in the performance-of the work for which this permit is issued, I shall Pnot employ anyperson �i.n ,such manner as to become subject to Workman's Compensation <br /> 1-aws-�-o-f�-Ca1•i-forn.i_a_� <br /> I WILL CALL FOR A GROUT IN CTION PRIOR TO GROUTING AN A FINAL INSPECTION. <br /> SIGNED ! TITLE: DATE: 0 <br /> 1,4_DRAW 'PLOT PLAN ON REVERSE IDE <br /> ;F R DEPARTMENT USE ONLY <br /> PHASE I DATE 9-4 -1 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : ! <br /> PHASE II GROUT INSPECTION ./ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />