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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date"Issued. <br /> LoComplete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <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 /> EXACT STREET ADDRESS 8�.�� ,�/y �e [.� CITY/TOWN h _ <br /> Owner's NameJ�►1os C��,s .�. Phone L?,7 r- Z <br /> Address4-27 G� . //T'� City c i <br /> Contractor's Nameit f r L/Y C54A ►c _� License#/f fav Phone me > <br /> IS CERTIFICATE OF WORKiAN'S COMPENSATIOfI INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN C1 RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION CJ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT C1 <br /> i <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 r' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We'll Excavation <br /> Domestic/private Drilled Dia. of,Well Casing 6 " <br /> �t'`--Domestic/public Driven Gauge ..of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor n Lr cin WC <br /> Type of Pump _r"4.4 s'► t :- H.P. l % - <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <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 accordant( <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 certi'f'ies 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 IN ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �--- TITLE: i DATE: J�/--�/1� <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I � _ DATE 7— <br />' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FNA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �:2 DATE_ .��-- <br /> 1 1'7 Q M <br />