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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> URAFFICE USE: K. 160. 1 E. Hazelton Ave. , Stockton, CA 95205 Permit No.'3-2,3 7 j <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 /> 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 incompliance with San <br /> JoaQui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 1 2 0 So "Ar,-,K.C+.L, CITY/TOWN <br /> Owner' s Name Q � eE�c��.w, .sT1�1- Phone_R -- <br /> Address 1'1 l Zb S o_l � �c +�c. - Ci tycsc.c�-t.o <br /> Contractor's Name License# Phone - 3 YSX <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN ❑ RECONDITIION [D DESTRUCTION❑ - - <br /> WELL CHLORINATION ❑ WELL ABANDObMENT ❑ OTHER ❑ �- <br /> PUMP INSTALLATION ( PUMP REPAIR E PUMP REPLACEMENT ❑ `J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES30 ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT -- OTHER <br /> PROPERTY LINE38' PRIVATE DOMESTIC WELL (&� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "4 <br /> Industrial Cable Tool Dia, of Well Excavation 12 <br /> Domestic/private Drilled Dia. of Well Casing !z" <br /> Domestic/public Driven Gauge of Casing /o <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 _t &M 0 1 <br /> Type of Pump 5 u15 mgrtztac H.P. 2,O <br /> PUMP REPLACEMENT: FIState 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 accordancq <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 emnFO <br /> any son in such manner as to become subject to Workman' s Compensation <br /> laws oifor i <br /> I WILL CALA G 0 T INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED F TITLE: ,AJX-J`? DATE: F00, <br /> DRAW PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY fic/ DATE — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION Bye DATE —Z� <br /> EH 1426 ___ Rev. 12-77 /78 2M <br />