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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - -7 <br /> This Permit Ex ires 1 Year From Date Issued <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. ~7 O 5-,? -V - LG4-r SA-s--A4 <br /> EXACT STREET ADDRESS/R, , Fh, k A1,5:0# � d 4' it . , CITY/TOWN e-r k 7C- �xr <br /> Owner's Name Phone ' <br /> Address !�216 <br /> C i ty <br /> Contractor' s Name IVfti , ,,� ,f �_ License# Z Phone ' ► <br /> IS CERTIFICATE OF WORKMAN'S C04 P NSATIO`N I�3SURA"10E ON FILE WITH SJLHD? YES i. NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT .. <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LIMES 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 Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing JA <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 /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor6�?oves ;PeA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑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 accordancE <br />. with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> F,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 ALL FOR A GROUT_JNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE' DATE: <br /> DRAW PEOT PLAN ON RE' RS DE <br /> FOR DEP RTMENTlaUSE ONLY <br /> PHASE I <br /> f z <br /> APPLICATION ACCEPTED BY `. � '� DATE --t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -- — - - -- , 1-7Q 9M <br />