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(v SAN JUAQUIN. LUCK HEAL1 H DIS I RIL I <br /> FUR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 FDate <br /> t Na. <br /> r <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued / <br /> This Permit Expires -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 /> 4oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Leo a`l Health <br /> District. Cvvk Rodd ori is/Grh d PC.• 16,19 9A016P ,7- <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name -De T fJF )OV 8 LeC WOIE'K-S �.-�' �'DU T Phone <br /> Address /9/0 . 7 ,4 Z,L TtJ -'czT City <br /> Contractor's Name /Voo %�f' r,4A3&W .E S Li cense# Pf,'?W Phone 9%6- 37/-623se- <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES K NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION S .� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ q <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 2 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DZ—Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal vLL <br /> Cathodic Protection =Rotary Type of Grout CDwG. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by_: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Z letApproximate Depth <br /> Describe Material and ProcedurJ7 les <br /> d ri v P <br /> I hereby certify that I have prepared this application and that the work will be done in accordar' <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 FOR-A GROUT INSP ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 4-ss/ HATE: <br /> DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR D PART ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1EH 1426 Rev. 2-77 _ - 1178. 2M <br />