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SAN JOAQUIN LOGAL.HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2g- 5,3_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION F`OR WELL. CONSTRUCTION OR PUMP PERMIT Date Isslaed S�/0-7.9 <br /> This Permit Ex ires 1 Year From Date Issued <br /> i Complete In Triplicate <br /> Application is hereby made to the San' Joaquin Local . Health District for a permit to construct <br /> and/Ur install the work-11herein describ6d: 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 n <br /> District. l.� `l.! <br /> RX{{ACT STREET ADDRESS ? �° ��`� CITY/TOWN <br /> ( 'rner's Name Phone <br /> k Pdress 7 s— City <br /> f <br /> contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKtiP,N'S COQ"PENSATIO'N INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONS' r <br /> WELL CHLORINATION —.WELL-RSANDONMENT ❑-.-=.O-..HER ❑- <br /> i PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <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 �1 `� Other Other Information <br /> Geophysical 1 °.� Surface Seal Installed by: <br /> i <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP= REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: �Well Diameter g cr Approximate Depth (� <br /> Describe Material and Procedure <br /> 3, <br /> I hereby certify that I.Ihave 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. Homeowner 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 ILL CALL FOR A GR9UJ7 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> s <br /> S GNED 0 i f TITLE: DATE: <br /> DRAW-PLOT,.-PLN_ON_..REV-ERS.E -SIDE.)— <br /> FOR <br /> SIDE.FOR DEPARTMENT USE ONLY <br /> � PHASE I �� � <br /> ` APPLICATION ACCEPTED DATE "7 <br /> ADDITIONAL-COMMENTS <br /> 11 <br /> I I ROUT INSPECTION <br /> „- - <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY !!. DATE INSPE TIO BY QAT i p <br /> � g a <br /> -AA9A 1?nu 7 —77 JlD ?�rc S.�+•^�JQ - `� C <br /> �7�2M <br />