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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOR OFFICE USE: 1601 E. Hazelton _Axe. , Stockton, CA 9520.5 Permit No. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /- y <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. perhit. to construct <br /> and/or install the work herein described. This application is made in compliance_ with S-an <br /> ,oanuin County Ordinance No. 1862 and the Rules and -Regulations. of the San Joaquin Local Health K <br /> District. <br /> EXACT STREET ADDRESS �p / . %t t L.-L /Q� __ CITY/TOWN/�c a � <br /> Detw-sv-� _rtJ r rGe )'.aAJ Phone?3! �a8 <br /> Owner's Name �..,,.�,,... � _ _ ,�--- -- 4 <br />.Address � �/` " 1 City <br /> Contractor's Name ovicA W C iLZrA/cfLicense#,35/p%,z3 Phone A8—/17 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'f INSURA�lCE ON FILE WITH SJLHD? YES NO <br /> TYPE OFWQR:K(Check) NEW'WELL0 DEEPEN ❑� RECONDITION ❑ DESTRUCTION dT 'WELL CHLORINATION 0 WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION PUMP. REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI/'��IfNES/d4 PIT PRIVY el is <br /> SEWAGE DISPOSAL,FIELD CESSPOOL/SEEPAGE PI ,OTHER <br /> PROPERTY LINE Q PRIVATE WEL •PUBL�QOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool s Dia. of Well Excavation la <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge 'of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal LIO <br /> Cathodic Protection Rotary Type of Grout 7- <br /> Disposal <br /> Disposal - Other`- Other Information <br /> Geophysical k Surface Seal Installed by: Qg1L -gye <br /> PUMP INSTALLATION: Contractor k.Log`ic.A L. 1 L-J- rco <br /> Type of Pum ,q�,OfgoV-v �r, - - H.P. <br /> PUMP REPLACEMENT: Q State Work Don6 3 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materialiand 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 Locall <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 ' I <br /> not employ any person in such manner as to become subject to Workman's Compensation r <br /> laws of California." r <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTITON T PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �? - 7 y INSPECTION BY DATE: <br />