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SAN JOAQU.IN LOCAL-.HEALTH DISTRICT <br /> -OF FIC USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No.-;7e-7 T <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S /� <br /> This Permit Ex Tres 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. <br /> EXACT STREET ADDRESS I <br /> CITY/TOWN <br /> L7" 1 .- --- _ <br /> Owner's Name Phone <br /> _ �, � �, 6-1-7--:Z <br /> Address City <br /> Contractor's Name ,, /, � �,,�. Li cense ter--- Phone -r <br /> IS CERTIFICATE OF WORKMAN'S COFIPENSATIO f I'NSURAINCE ON FILE WITH SJLHD? YES IN0 <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 RECONDITION ❑ DESTRUCTION d � <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATIOl PUMP REPAIR 0 PUMP REPLACEMENT ❑ l� <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 <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 'c--Domestic/public <br /> Domestic/private Drilled Dia. of Well Casing �-�. <br /> Domestic/publ i c Driven Gauge of Casing - - -�--~ <br /> Irrigation Gravel Pack Depth -of Grout Sea <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <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 /> 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 NSPEC IO RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEQ TITLE: DATE: ,�— d <br /> DRAW PLOT PLVN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��f�t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS -.- <br /> PHASE <br /> OMMENTS :PHASE II GROUT INSPIECTION. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE -7 _ <br />