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SAN JOAQUIN .LOCAL HEALTV DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton,`-CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) r <br /> W <br /> Application is hereby made to the San Joaquin Local Health District for a permit onstruct <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. bll/l��q n 205-1sz- /3 <br /> EXACT STREET ADDRESS/V, sir/t � �*i-� a„ /(I of Grs L�ITY/TOWN�Fc�.��«„ <br /> 'Owner's Name-c�,a,, 1e7< e lr,ILI Phone oc _g3Y-p�_rt <br /> Address , 'o 0 ./:Z,-"^I L Al , Cit <br /> 'Contractor's Name License#?,?g//u Phone 2 M1 <br /> I5 CERTIFICATE OF WORK"IAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION(] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANI(CD�+ SEWER LINES 4 { PIT PRIVY <br /> SEWAGE DISPOS% FIELD ����� CESSP OL/SEEPAGE PIT — OTHER— <br /> PROPERTY LINE/-4PRIVA�E�0 ESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ") <br /> Industrial __X�Cable Tool Dia. of We Excavation /z/ " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Ile <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout — <br /> Disposal - Other Other Informatioon <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: , Contractor <br /> ;.Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 performance of the work for which s permit is issued, I shall <br /> not employ any person in such manner as to become sub, -c' Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL-FOR AROU IN4 ION PRIOR TO GROUTING AND A FINAL INSPECTION. SS <br /> SIGNED TITLE: aqe,v / DATE: 2 Z <br /> PL ON REVERSE' IDE <br /> PHASE I <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3-,-)6- -7 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE II VIWL,7INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -DATE­g,;--e- <br /> EH <br /> eEH 14 26 Rev. 9/719 Q/7A M <br />