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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No-Z?-/-s`6,7 r <br /> Telephone: (209) .466-6781 <br /> APPLICATION FQ WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date- Is-sued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct \I <br /> and/or install the work herein described. This application is made .in compliance with San <br /> ,'oaouin County Ordinance No. 1862 and the Rules arid Regulations of the San Joaquin Local Health <br /> District:. <br /> EXACT STREET ADDRESS Z 2 CITY/TOWN ; <br /> Owner's Name Phone�T/ 9122. 1 a <br /> Address City. <br /> Contractor' s Name f / t License f �,> Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE O1` " FILE WITH SJLHO? YES Z�NO 11 <br /> TYPE OF WORK (Check) : NEW WELL9J-- DEEPEN ❑ RECONDITION Q DESTRUCTIONE3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION MP REPAIR❑ PUMP REPLACEMENT [ ?V1� <br /> DISTANCE TO NEARES`�: SEPTIC TAMC EWER LINES PIT PRIVY <br /> _ SEWAGE DIS OSAL LD 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 /� t <br />-X�D.omestic/.private Drilled Dia, of Well Casing_�xj�� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout s I <br /> _Disposal Other Other Information` <br /> Geophysical Surface Seal 'Installed <br /> PUMP IN Contractoro!2e;�—�- 74.,z �t A25---- <br /> Type of Pump H. .� <br /> PUMP' REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Done r <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 <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,jto became subject .t.o. Workman 's Compensation ,L <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A4- NA INSPECTION. <br /> SIGNED ` -TITLE: DATE: <br /> DR W <br /> FLUI PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE //-/- .7t <br /> _ <br /> APPLICATION ACCEPTED BY �. ' <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C•, DATE 12- <br /> ` <br /> 5 <br />