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wft <br /> AN JUAQUIN LUCAL HEALTH Ul5IKIUI� <br /> R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,-.7 <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/-/,7-,7y <br /> This Permit Expires 1 Year From Date Issued <br /> r. (Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rid/or install the work herein described. This application is made in compliance with -San <br /> toaquin County Ordinance No. 1862 and he Rules and Regulations of the San Joaquin Local Health <br /> District. 2 S' 7 fi_, j �., / 2� <br /> XACT STREET ADDRESS / —f C0V nAt j)K J r-1 Al 6 i2,Z l.- CITY/TQWN � <br /> Owner's Name,h Az IZq v <br /> Phone � ��G <br /> ddress �0 q9(� se < P X�i7wv 1� � City_ <br /> Contractor' s Name, , � � n�v License#o?V0/() Phone v? }y <br /> 'S CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> �T_YPE OF WORK (Check) : NEW WELL DEEPEN L7 RECONDITION ❑ DESTRUCTIOfd[� <br /> WELL CHLORINATION E] WELL ABANDONMENT CI OTHERP§ <br /> .. PUMP INSTALLATION f4 PUMP REPAIR❑ PUMP REPLACEMENT by 04lW etc.., <br /> 9ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ` Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information J <br /> Geophysical Surface Seal Installed by: <br /> SUMP INSTALLATION: Contractor -71 <br /> Type of Pump �_ H.P. <br /> „'UMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: Q 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 accordai <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loci <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 /> -w not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL R A GROUT WPEPTION PRIOR TO GROUTING AND A F NAL NSPECTION. <br /> "SIGNED TITLE: DATE: -- <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> "PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> b. PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION By%j,P DATE///Yl-7rj <br />