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r- SAN JOAQUIN LOCAL HEALIH U1JIK1I ' <br /> FOR OFFICEUSE: 160 Hazelton Ave. , Stockton , CA 205 Permit No. 7� 2y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> ADplication 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 /> ,:oaquin County Ordinance No. 1.862 and the Rules and Regulations of th S n Joaquin Local Health _ <br /> District. l� �'�� � " vJ�J��J�Uo) <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name � �� to Phone ho ic_ <br /> Address c a , City <br /> Contractor' s Name <br /> JA Ki �� � ���,� icense#:3, j jyyPhone r _ <br /> 0 <br /> IS CFRTiFICATE OF WORKMAN'S CON'PENSATION! INSURANCE ON FILE WITH SJLHD? YES >L- NO O <br /> TYPE OF WORK (Check) : NEW WELLtg DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION �4 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKncyLe SEWER LINES �t n of PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation __j � <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /,a <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout9SK -An 4�rm �e — 4 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: ctrylt � �c�J <br /> PUMP INSTALLATION: Contractor Ari ci. S CAn,.l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [7 State Work Done <br /> PUMP REPAIR: ❑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 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. " 1j <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED &,"N TITLE: [),,u DATE: ///3 / 7 <br /> DRAW PLOT PETN ON REVERSE SIDE <br /> PHASE I FO DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE / 1-717e <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY T��� DATE 1..2z�' j <br /> EH 1426 Ppk/ 1 ?_77 � � 1 i7R 9M <br />