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SAN JOAQUIN LOCAL.HEALTH DISTRICT <br />_ FOg OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No• !2 <br /> Telephone: (209) :466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued .P 7-"7 <br /> a <br /> This Permit Expires 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 - VQVj2 L A AlfAea, s CITY/TOWN <br /> 4 <br /> Owner's Name rCF -4 MAe "l—Ar ��494"Cid --- Phone <br /> Address L. Cit <br /> yA <br /> Contractor' s Name X,7License# o, Phone 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO`! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I❑ RECONDITION [D DESTRUCTION <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION CI PUMP REPAIR❑- PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES d/--'PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD b,01 CESSPOOL/SEEP GE PIT OTHER <br /> PROPERTY LINE -. PRIVATE 'DOMESTIC WELL�.f.� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYP,E 'OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .. Cable Tool Dia. of Well Excavation ,$ �� <br /> Domestic/private Drilled Dia. of Well Casing F /� -- <br /> Domesti c/publ-i c L Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 6-0 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: Q 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ®i',, ��.�'�., <br /> DATE: Ac- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMEN USE ONLY . <br /> PHASE I DATE 3— .3-` <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPE BY DATE ►1 S <br /> - Glr►. . s,eA4 a e-vt.o Z 0 re at-mo-, r► �r <br />