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1N JOAQUIN LOCAL HEALTH DISTRIC' <br /> 'OFFICE USE: 160;x! Hazelton Ave. , Stockton, CA �05 Permit No. <br /> Telephone: (209) 466-6781 <br /> -- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_/__g._�� <br /> This Permit f_xfires 1 Year From Date Issued <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 L1AE_J-17-Y kD _ CITY/TOWN (/QCT <br /> Owner's Name _�(9 ' L&60 Phone_ -� 1Y <br /> Address �/ �, Lj�i�i�'7Y 7) City 6,AJ— 64- <br /> Contractor's Name 61PSoAl Oja -D,0rLCZA((4 License# C7 Phone Z�M-33"77_ <br /> IS CERTIFICATE OF WORKiIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES )C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION g DESTRUCTION[ <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR O PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK $C SEWER LINES j O f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE4O PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial K Cable Tool Dia. of Well Excavation /Q" <br /> _Domestic/private Drilled Dia. of Well Casing pF-c/t4F $'0 <br /> Domestic/public Driven Gauge of Casing /Ca <br /> Irrigation Gravel Pack Depth of Grout Seal 4EXJs riAl <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other InformatioT n <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done_ <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan, <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 OR A GR T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ��� ° TITLE:,_L_'/__ <br /> DRAW PL PL7CN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIOADDITIONALLNCOMMENTSCCEPTED BY )� �_ DATE 1-2 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE_ <br /> FH 19.9r, De.. 10_77 /7R 9M <br />