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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 7.. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7��p <br /> Telephone,: (209.) 466-6781 <br /> APPLIiCATION FOR WELL SONS,TRUCTION OR PUMP PERMIT Date Issued7;P <br /> This Permit Ex fires 1 Year From Date Issued <br /> .j 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 />;Joaqui'n County Or.Uin`ance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. II <br /> EXACT STREET ADDRESS 6� CITY/TOWN <br />,Owner's Name-. !� Phone j179— a7 <br /> Or . . .� <br /> 92-6 <br /> Address 292s iCi ty"` <br /> Contractors Name--A./1. etl.Z Q1 License# ��'Phone, 2�/Z ,2LE T <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check): NEW. WELL� DEEPEN ❑ RECONDITION DESTRUCTION❑ — � l <br /> I!f WELL CHLORINATION p WELL, ABANDONMENT 0 OTHER 0 <br /> iPUMP INSTALLATION IN PUMP REPAIR CD PUMP REPLACEMENT ❑ ; <br /> DISTANCE TO NEAREST:: SEPTIC TANK / D, SEWER LINES PIT PRIVY <br /> ISEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USEj� TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial !' Cable Tool Dia. of Well Excavation_ %- j <br /> ___2�___Domestic/priv,ate Drilled Dia. of Well Casing Fif <br /> Domestic/public Driven Gauge of CasingT `L o <br /> Irrigationj� Gravel Pack Depth of Grout Seal P <br /> Cathodic Protection =Rotary Type of Grout e <br /> Other , <br /> y r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor - <br /> T pe of Pump H.P. ,0 <br /> PUMP REPLACEMENT: [J State Work Done ; <br /> PUMP REPAIR: (State Work Done <br /> DESTRUCTION OF WELL:---Well • Di-ameter Approximate Depth <br /> Describe Material ana 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 licensed agent' s signature certifies the following: <br /> "I certify that in the per-foninance 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. 1 <br /> SIGNED 1,� TITLE: DATE: / IA e 7 - j <br /> M DR W PLOT PLN ON REVERSE SIDE <br /> !I' FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION-ACCEPTED,-BY �,:� DATE - . � a� 7� I <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUTINSPECTION PHASE III FINAL INSPECTION <br /> IN$PECTiON BY. ;�—_AJ� � S!. INSPECTION BY D TE - - <br /> DATE CU lAne <br />