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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No.7g-/,s-a�- <br /> Telephone:( 209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,_,�9-.2,,�>g <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> sand/or install the work herein described.. This application is made in. compliance wi-th' San <br /> dOaoui n County Ordinance No. 1862 and _the Rules and Regulations of :the San Joaquin Local .Health <br /> District <br /> EXACT STREET ADDRESS >J ,J /�,e AlL<'IJ �� CITY/TOWN 42� <br /> Owner' s Name Tiota►-�,�14t Phon� - <br /> Address (A •3 7 CC-OA or- Cit <br /> Contractor's Name v LL /.�/-.LL/�vCl.icense# Phone /6 72? i <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLEX DEEPEN 0 RECONDITION <br /> WELL CHLORINATION d DESTRUCTIONE3 � { <br /> PUMP INSTALLATION -�. PUMP REPAIR p NT PUMP REPLATHERCE ENT ( y <br /> DISTANCE TO NEAREST: SEPTIC TANK/coo/ SEWER LINES/Sud :PIT" PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC �WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS y <br /> _Cable Tool Dia. -of Well Excavation /;Z <br /> _Domestic/private Drilled Dia..' of,-Well Casing YZI <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type' of Grout`:: <br /> Disposal Other Other 'Informa=tion <br /> Geophysical Surface Sea-l.- Installed by:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pum <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> = Approximate Depth , <br /> Describe Materia an Procedure <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> vith San Joaquin County Ordinances , State laws, and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner or licensed agent's signature certffi-es- the­following: <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. " =a, <br /> WILL CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED <br /> DAT E <br /> DR W PLOT PL N ON REVERSE IDE <br />'HASE I FOR DEPARTMENT' USE ONL Giddreq 37 c'" or �arh <br /> PPLICATION ACCEPTED S <br /> Y << 2 ATE (/ <br />,DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PP44SE I FIN L INSPECTION <br /> NSPECTION BY DATE INSPECTION <br /> DATF�- p <br /> Rov 17_7'7 } <br />