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" SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> to FB 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. y t ,ga <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5�5=?' <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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET.ADDRESS CITY/TOWN,��o <br /> Owner's Name_ FN �i0.ac Phoney/S/ -`c�/? 'j <br /> Address c/ vts - - _ R: City_ <br /> Contractor's Name"X240 wt ady,a Licensee Z//y_ Phone 2yZ-2k1b <br /> IS CERTIFICATE OF WORK'iAN'S COMPENSATION INSU ANCE ON FILE WITH SJLHD? YES x NO <br /> TYPE OF WORK (Check) : NEW WELL Q0 DEEPEN ❑ RECONDITION Q DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANkSi l SEWER LINES,Sd I PIT PRIVY <br /> SEWAGE DISPOSAy FIELD . O CESSPOOL/S GE PIT OTHER-�. <br /> • PROPERTY LINOL4PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WeI7 Excavation 41 <br /> '+ <br /> Domestic/private Drilled Dia. of Well Casing '+ <br /> Domestic/public Driven _ . Gauge of Casing iz <br /> "Irrigation �Gravel 'Pack Depth of Grout Sea <br /> Cathodic Protection. Rotary Type of Grout 4„� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 1-51AI"C04 <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump H. <br /> PUMP REPLACEMENT: 0-State Work Done <br /> PUMP REPAIR: O State-Work Done <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 accor <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin L <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 CALL F05 A 4ROUSPECTION PRIOR TO -GROUTING AND A FINAL INSPECTION. <br /> SIGNED� TITLE: DATE:6 <br /> (DRAW PLOT � ON REVERS9 SID€j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� �' n, <br /> APPLICATION ACCEPTED BY �fmda% ,,.., /`'rcDATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />