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SAN IJOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.J,2-,g 2 2- <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issueds_ <br /> (Complete In 'Triplidate). <br /> Application is hereby made to the San Joaquin Local4Health 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. 1862 and the Rules and �Regulations of the San Joaquin Local Health <br /> 'District. <br />'EXACT STREET ADDRESS o1 V/ k 9 -Al, TLA L-L Y CITY/TOWN ,4CG1 t;�.) 0 <br /> Owner's Name S a Phone <br /> Address /LAi1 .� /l/0- City <br /> Contractor's Name ,c/, r'LL /LL/1vGLicense# / 23 Phoned _ A, 7 <br />.,IS CERTIFICATE OF WORKFIAN'S�CO"1PENSATIQM INSURAINCE ON FILE WITH SJLHD? YES O JC <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [] DESTRUCTION d <br /> WELT. CHLORNATION 0 WELL ABANDONMENT 0 OTHER 0 'Z <br /> PUMP INSTALLATION , PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> PDISTANCE TO NEAREST: SEPTIC TAN , SEWER LINES�.!oc��, PIT PRIVY VO' K/a- <br /> SEWAGE DIS OS�IELU/,�.�CESSPOOL/SEEPAGE PIT2�—.OTHE-R <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLMQat-PUBLICDOMESTIC WE� l.L ��� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private gilled Dia. of Well Casing Af <br /> Domestic/public Driven Gauge of Casing a� <br /> Irrigation Gravel Pack Depth of Grout Sea t ' <br /> Cathodic Protection Rotary -. Type of Grout C /vL a <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ���i 'r 1, G /� LL n1 <br /> Type of Pump_ g= ,,;d <br /> -ham - --- H.PUMP REPLACEMENT:REPLACEMENT: ❑State Work pone <br /> PUMP REPAIR: ❑State Work Done . ` <br /> DESTRUCTION OF WELL: Well Diameter F Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby .certify—that I -have prepared-thi-s:­applicati-on- and that the'work-wi1Tbe done in 'addordance <br /> With San Joaquin County Ordinances , State Laws , and Rules and Regulations of- the San Joaquin Local i <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 suchma ner as to become subject to Workman's Compensation <br /> laws of California. � ,' <br /> I WILL CA FOR A GROUT INSPECTION RIOR TO GROUTING AND A'FINAL INSPECTION. <br /> SIGNED TITLE: DATE:.-5_-' -'k <br /> (DRAWPLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> NP—PLICATION LICATION ACCEPTED BYZ/24_�h& D!-t DATE s <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE��� dr7 <br /> EH 14 26 Rev. 9/780i7n - o y <br />