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SAN JUAQU1N LUCAL HEALIH U1SIR1L1 <br /> FFICE USE: I - 1601 E. Hazelton` Ave. , Stockton, CA 95205 Permit No. 7:7�� <br /> Telephoner (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued <br /> This Permit Expires 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 /> ,'oaQuin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin .Local . Health <br /> District. <br /> EXACT STREET ADDRESSa CITY/TOWN d r <br /> Owner's Name _ ,v, Phone Q : gL Z <br /> Address—IM- <br /> Contractor' s <br /> ddress $'� . Cit / <br /> Contractor' s Name License# Phone -- Q <br /> y7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"3 'INSAANCE ON FILE WITH SJLHD? YES 4-' NO <br /> TYPE OF WORK (Check) : NEW WELLUP— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER(. <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DIS POSIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> PROPERTY LINU-O#RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /-2- <br /> << Domestic/private Drilled Dia. of Well Casing _ K _ <br /> Domestic/public Driven - Gauge of Casing --Z- rt <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Y_,&,Rotary Type of Grout ���, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by_ , illw1 f,- fin, <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 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNEDTITL DATE: 3 1.11 <br /> DRW PLT PL N ON REV RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ---7, <br /> ADDITIONAL COMMENTS : <br /> PHASE II MOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E` DATE ,2;L� ;'k <br /> 1426 Rev. 12-77 _- �_IJ7-8- . 2M J <br />