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SAN JOAQUIN LOCAL HEALTH DISIRICI <br /> FOR FFI"CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7y_1&Zp �s <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 /> omp ete In Triplicate 203---oq-6_0Z <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or ;nstall the worts herein described. 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 <br /> District. , <br /> EXACT STREET ADDRESS ,, , r .. i' ' = =: CITY/TOWN <br /> Owner's Name , <br /> ,, ,� tA, Phone <br /> Address /w ., :: ftp �.� ,_, City c ". _ <br /> Contractor's Name �. - .y { f � - , a License#_r Phone r - r. f. <br /> IS CERTIFICATE OF WORIClAN'S COMPENSATION InSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER 0 4)PUMP INSTALLATION [3 PUMP REPAIR® PUMP REPLACEMENT ❑ rJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPUS-AL-TIELD CESSPLIUL/SEEPAGE _P71 _ OTHER <br /> PROPERTY LINE -. PRIyATE D-ffESTIC WELL PUBLIC D-UM-ESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustria Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <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 y: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Proce2ure <br /> I hereby certify that 1 have prepared this application and that the work will be done inactor ce <br /> with 'San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin L al <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 :�- '�"".�- , r`, �_ ITLE: ;*,• DATE: - , ��'' <br /> . ,�DRAW PFnT P FON REVERS 7 - t <br /> �FORDEPARTMENT <br /> SE N <br /> PHASE I � � ,� le. � <br /> TP-PLICATION ACCEPTED BY - s� � DATE ' r 7, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> L'U" T A9G e;..: 1 e '7'7 l /79 7M <br />