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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />_.�Q�( F.FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 EDate <br /> t No.�9 <br /> Telephone: (209) 466-6781 Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 per to construct <br /> and/or install the work herein described. This application is made in cam ance with San <br />�oaqui n County Ordinance 1,1o. 1862 and the Rules and Regulations of the n Joaquin Local Health <br /> DiStr�ct. / [�� <br /> EXACT STREET ADDRESS �/ / CITY/TOWN 6�C � r <br /> Owner' s Name 410eaii A Phone <br /> Address 2 4/7 6 4-0 City <br /> Contractor's Name ���f}1� Mei✓ License# _ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI0,1 ItISURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.,ABANDONMENT Lam, OTHER 0 Q <br /> PUMP INSTALLATION PI PUMP REPAIR❑ PUMP REPLACEMENT❑_. --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ifs <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLICO DOMESTIC WELL <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 <br /> Geophysical Surface Seal Installed by_: <br /> PUMP INSTALLATION: - -Contractor '-.S LE.4 /� 14AAL -7� <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 and Face ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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 A FINAL INSPECTION. <br /> SIGNED ; TITLE: DATE: 2 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1178 2M <br /> Pu 1 a9A Doti 17-77 <br />