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!1 : - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit NoMy-�4- <br /> APPLICATION <br /> Telephone: (209�)A 466 .6781 <br /> F 4/�C FOR WELL CONSTRUCTION OR PUMP PERMIT 1k I Date Issu <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San�lJoaquin 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 /> ,oanuin County Ordinance No. 1862 andgthe Rules and- Regulations of the San Joaquin Local Health <br /> DisLr'ct. <br /> EXACT STREET ADDRESS ��� _ Q` /(/P ( � l7 CITY/TOWN <br /> Owner's Name "ff 117 l Phone <br /> Address !I City <br /> Contractor' s Nave Licens Phone �f� Z <br /> IS CERTIFICATE /OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTIONC] <br /> WELL CHLORINATION0 ._-WELL ABANDONMENT-0 OTHER 0- <br /> 'PUMP '!NSTALLATION ( PUMP REPAIR n PUMP REPLACEMENT t] <br /> y: <br /> E DISTANCE TO NEAREST: SEPTIC TANK D_fi-5EWER`L'l-NES ' J-PIT PRIVY <br /> SEWAGE DISPOSAL .,�....II-EL-D---��-a--..CESSPOOL/.SEEPAGE_ T_. --.._ OTHER <br /> 19 <br /> "PROPER-TY LIN�'PRIVATE DOMESTIC WELLjE-0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 'ove-- <br /> `% Domestic/private Drilled Dia. of Well Casing 5 + ctl <br /> Domestic/public Driven Gauge of Casing /40 G: <br /> Irrigation Gravel Pack Depth .of -Gr'ou't ,Seal <br /> Cathodic Protection Rotary Type._of�Grout 1 > <br /> Disposal Other Other Information <br /> Geophysical <br /> , � y � .,a:�4� � Surface eal Installed ,b i <br /> PUMP INSTALLATION: Contractor -.. { S �• '' ' l <br /> Type -of4Pumpij 1 ,c H.P. i t <br /> PUMP REPLACEMENT: �F]State .Work: Done <br /> PUMP REPAIR: ', ❑State Work Done <br /> DESTRUCTION OF4-WELL: Well Diameter ll Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared':.ithis application and that the work will be done in aceordanc <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 performanceliof the work "fb-r 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 INSPE TIO PRIOR TO GROUTING AND A FIML INSPECTION. <br /> SIGNED �'�---- ; rTiE: S L DATES: 2-/ <br /> D W;,PLOT PLN ON REVERSE-SIDE) I r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F <br /> OAPPLICATION ACCEPTED BY !! DATE g .. <br /> ADDITIONAL COMMENTS : --- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY `�(y` DATE <br /> S.EH 1426 Rev. 12-77 1/78 2M <br />