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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOR ' USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. ,-,g 11,96 <br /> Telephone: {209) 466_-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g <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. 1:862 and the Rules and-Regulations of the San. Joaquin Local Health <br /> District. <br /> EXACT STREET <br /> JG %�J�/ /�8� �ac rapt 'Aie w 0hre'kITY/TOWN <br /> ADDRESS � <br /> Owner's Name Phone <br /> Address go 2r. MCity <br /> Contractor's Name , Licensed746(1L__ Phone :y - 6,J <br /> IS CERTIFICATE OF WORKMAN'S CO"4PENSAT/ INSURA !CE ON FILE WITH SJLHD? YES 4----.NO <br /> TYPE OF WORK'- (Check) :. . NEW WELL L DEEPEN 0 RECONDITION; -DESTRUCTION() <br /> WELL CHLORINATION D. WELL-ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR O PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE, DISPOSAL FIELD CES SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DWESTIC WELL PUBLIC D1Z�NESTIC WELL n� <br /> INTENDED USE TVPE .OF WELL CONSTRUCTION SPECIFICATIONS o <br /> Industrial C able Tool Dia. of Wel Excavation <br /> Domestic/private Drilled Dia. of Well Casing �h <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> -,PUMP INSTALLATION: Contractor <br /> Type of Pump H <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 /> 1 hereby certify that I ,havelprepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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 F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNETITLE: �0_1 %_- DATE: <br /> RAW PLO PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s`Lo— DATE / S� <br /> ADDITIONAL COMMENTS: A <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL INS T <br /> �J.INSPECTION Y C DATE 1 INSPECTION BY ,5=�d 4z- D <br /> \�2� s,_�'T '� . ems,--.--•-? 78 2hI <br />