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' ;Tip,. • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave..; Stockton, CA 95205 Permit NO. e� -5L <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued f <br /> (complete In 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. -((0g1 s7 S� ! �1-D`f0- �� <br /> EXACT STREET ADDRESS ,= fes A' CITY/TOWN <br /> Owner's Name f. r FPhone <br /> Address i . „r.. City <br /> Contractor's Name ,_,, . , �' °° "11 Li cense# s Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAI•JCE ON FILE WITH SJLHD? YES � 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Q <br /> PUMP INSTALLATION CI PUMP REPAIR❑A PUMP REPLACEMENT Q <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 <br /> Industrial Cable Tool Dia. of We 1 Excavation <br /> Domestic/private. Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ,, Irrigation Gravel Pack Depth of Grout Sea <br /> - Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor `� ,� �'� - � <br /> Type of Pump - H. <br /> PUMP REPLACEMENT: ❑State Work Done_ <br /> PUMP REPAIR: ❑State Work Done - ,° / 01 4V , { �� -- <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 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 />� $IGNED »— a Y `.� :a " '. TITLE: ,� g DATE: S t <br /> ,v �DRAW -PLOT PLAVON REVERSE SIDE). <br /> 4 -' FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> F <br /> PPLICATION ACCEPTED BY _ �_ . DATE4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ' III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION .BY - DATE <br /> PW 1d 9f Djaw 0/70 Q/7Q 7M <br />