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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (2.09) 466--6781 <br /> --- - ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 3J'r <br /> This Permit Expires I Year From Date Issued <br /> d Complete In Trip i cate <br /> Application is hereby made to ,the San Joaquin Local Health District for a permit .to construct <br /> and/or install the work herein1described. This application is made in compliance with San <br />'eanuin County Ordi nce 'a. . 1862 and the ul s and Regulations of the San Joaquin Local Health, <br /> District. e- <br /> EXACT STRE T ADDRESS J CITY/TOWN A 1�C <br /> Dwner' s Name �.,_,..._� c� P l�_a PhoneAddress 035-035- J01,7P _ City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S 6'IPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> F <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [Nt J' <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 /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> 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 /> Geophysicalk � �.,." Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of1Pump H.P. <br /> PUMP. REPLACEMENT: []State Work Done y <br /> PUMP REPAIR: [,]State Work Done' z. . <br /> DESTRUCTION OF WELL: Well Diameter Approxima a Depth t <br /> Describe Materi a and�Proce" ure <br /> I hereby certify that I have'preparft' d this app�ica"tion and that� the'work will bed one—in accordance <br /> with San Joaquin County Ordinances, State 'Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth 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 Compensa -on <br /> laws of California. " _ <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR- TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: ` DATE: <br /> x DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ON Y � <br /> CHASE I . k <br /> UPPLICATION ACCEPTED BY !L%t1 7 DATE C� c <br /> 4DDITfONAL COMMENTS: <br /> PHASE II GROUT I ECTION PHASE III FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY DATE Z 72E——T <br />.H 147Fi Raw 17-77 1 179 2V <br />