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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1 1601 E. Hazelton.Ave. , . Stockton, CA 95205 Permit <br /> Telephone: . (209) 466-.6.78.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Thi4s. Permit Ex fres 1 Year From Date Issued -f - <br /> . Complete In Trip] icate. <br /> Application is hereby made to !the San Joaquin Local Health District for a ermit to construct <br /> and/or install the work herein 9 <br /> described. - This application is- made in compliance with San - <br /> Joaquir County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin 'Local -Health <br /> GiStr�ct. � <br /> EXACT STREET ADDRESS JO S X CITY/TOWN lVdw, a <br /> Owner's Name N, a WIA LIZ Phone 239—g2 l�f <br /> Address. - _ <br /> j city <br /> Contractor's !Name � ;.l License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION` 01 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ N <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT,' J.l <br /> r <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5, <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public EI Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection `I Rotary Type of Grout <br /> Disposal ti Other Other Information <br /> Geophysical A Surface Seal Installed b . <br /> PUMP INSTALLATION: Contractor <br /> l� <br /> Type ofJPump p H.P. <br /> PUMP REPLACEMENT: (l State Work Done <br /> PUMP REPAIR: ❑Statfe Work Done <br /> DESTRUCTION OF WELL: Well Diameter tr Approximate Depth Z.S: <br /> ;F <br /> De.scri be Mateand Pro.cedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordant(! <br /> aith •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 to become subject to Workman's Compensation <br /> laws of California. " -.•'i) <br /> I WILL CALL FOR A ECTIO TO GROUTING AND A FINAL INSPECTION. <br /> i <br /> SIGN _ .-TITLE: DATE: <br /> LOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDBY c DATE Z�—�� � <br /> ti <br /> ADDITIONAL COMMENTS: iI <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY % DATE INSPECTION BY DATE <br /> ZZ�l <br />'_H 1426 Pjav' 19-77 .. �, 1"70 0M <br />