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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE 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 ` 7 <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations ..of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ,3� CITY/TOWN ' <br /> Owner's Name Phone,, C -„ S'"�(�6.2_, <br /> Address Ci ty .0 ncr- 4r i <br /> Contractor' s Name License# )0 2-3 Phone 3� ,,Cd <br /> IS CERTIFICATE OF WORKtIAN'S CO.IPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN El RECONDITION [] DESTRUCTION[] p� <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 "I <br /> PUMP INSTALLATION 49 PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z6 ” PIT PRIVY <br /> SEWAGE DISPOSAL FFIELDQ 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 6 'r <br /> `Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ` Gravel Pack Depth of Grout Seale <br /> Cathodic Protection .. _Rotary Type of Grout <br /> Disposal , ... . Other Other Information <br /> Geophysical,', Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump ` H:P. j <br /> PUMP REPLACEMENT: ❑State Work Done s <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 accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local 's <br /> Heal th-DaStr-i-ct:— Home-owner--or l-i-tensed-agent's -si-gn-attire 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 FW GROUT INS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PLAN ON REVERS IDE <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY 63 DATE Z3—, <br /> ADDITIONAL COMMENTS: _ T <br /> PHASE II GROUT INSPECTION PHASE III FINAL` INSPECTIQN <br /> INSPECTION BY DATEF INSPECTION BY DATE l'r✓ 7 j <br />`%riI Innc_, n._._ .,.In..-7-7 -1 /'7Q W <br />