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SAN JOAQUIN LOCALHEALTH DISTRICT fi <br /> I FOR FF CE USE:N 1601 E. Hazelton Ave. ,' Stockton, CA 95206 Permit No.,):Z-_9_/ <br /> 1p Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - - <br /> it <br /> II This Permi.t 'Ex ices 1 Year From Date Issued <br /> Complete I-n 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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACTSTREET ADDRESS 7??� S. �u r �B � .— CITY/TOWN <br /> Owner's Name ~rte,' /IjPhone_ <br /> Address 2 1111S. 'd, City CIc�Ac. <br /> Contractor' s Nam"e- Li cense#,f3 72.;j—Phone z --?G7 <br /> IS CERTIFICATE OF WORKMAN'S M NSATIO"! INSURA?!CE ON FILE WITH SJLHD? YES 'dQ <br /> TYPE OF WORK (Check) : NEW WELL C! DEEPEN ❑ RECONDITION ® DESTRUCTION E3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER-0 <br /> �I. PUMP INSTALLATION C7 PUMP REPAIR PUMP REPLACEMENT [] <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 /> INTENDEDI�USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation y <br /> _Domestic/private Drilled Dia. of Well Casing V } <br /> Domestic .public Driven Gauge of Casing _ 7 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposalli Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump ,� a H.P. <br /> `y <br /> PUMP' REPLACEMENT.: Q State Work Done <br /> PUMP REPAIR: M (RState Work Done d ,� <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 District0 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 l <br /> not employ any person in such manner as to become subject to WDrkman's. Compensation <br /> laws of California. " <br /> I WILL CALL FOR:1% GROUT IN.SP TION PR-ITO GROUTING AND A FINAL INSPECTION. <br /> SIGNLJmL/ `�.,� ITLE: DATE: <br /> R PL �PMNN N REVERSE SIDE <br /> FO DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY TEmio 00 r 19A <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PH FI AL INSPECTION y <br /> INSPECTION BY 1� DATE INSPECTION DATE <br /> EH 1426 Rev. 12777 1/7 8, 2M- <br />