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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Qg FFICE USE: 1601 E. Hazelton Ave- ,.Stockton, CA 95205 Permit No. 9- / <br /> Telephone; (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> a -� 9 <br /> (tainplete In Tri p1 i tate) � <br /> Applicationishereby 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 incompliance with San <br /> Joaquin County Ordinance No. 1862 and thp Rules and Regulations of -the San, Joaquin- Local 'Hea.lth <br /> District. j <br /> A�ZV_ <br /> EXACT STREET •ADDRESS ._ � �G�r? CITY/TOWN G <br /> Owner's Name C Phone <br /> Address . <br /> Contractor'„s Name J—Li cens Phone ' a ✓� l <br /> IS CERTIFICATE OF WORKMAN'S CO";PENSATIOfI INSUR ;lCE ON FILE WITH SOLHD? YES �� O <br /> TYPE. OF WORK (Check) NEW WELL DEEPEN0 RECONDITION DESTRUCTION[ .. a. � . <br /> - WELL CHLORINATION 0 WELL ABANDONMENT q OTHER Q - --� <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT Q.. t,� + <br /> DISTANCE TO NEAREST: SEPTIC TANK -71 SEWER LINE ._ ���PIT PRIVY � <br /> SEWAGE DiSPOS fIELD ' CESSPOOL/ S - PAGE PIT loo�f—OTHER <br /> PROPERTY LINE RIVATE QMEES.TIC W.E.LL ! "� -P.UBL-IC-DOMESTIC--WELL -- <br /> INTENDED-USE TYPE OF,.WELL _� --''"rCONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool 'Dia. of We l-�Excavation. �L <br /> �-- <br /> Domestic/private : i_ tilled Dia. of Well .Casing le, -�. <br /> Domestic/public Driven Gauge of'Casing S <br /> r Irrigation "t Gravel Pack Depth—of Grodt Sea � <br /> E Cathodic Protection �. rotary Type of Grout �tw <br /> Disposal Other Other Information <br />'4 Geophysical 'Surface Seal—Insta ed b n <br /> PUMP INSTALLATION: - Contractor <br /> 1&ffW114Q 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done , <br /> F PUMP REPAIR: C3Stat­ Done- <br /> DESTRUCTION OF WELL: biameter roximate Depth <br /> D scribe Material and Procedure <br /> I hereby certify tha -I have ! work wi 1 be one in accordance <br /> ' with San Joaquin Count ions— f 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 /> � y laws of California.." <br /> I WILL CALL F GROUT INSPECTION PRIOR TO GROUTING AND A F NAL''INSPECTION. .� <br /> SIGNED i TITLE: DATE: <br /> AW <br /> PL ON REVS SIDE <br /> FOR DEPARTMENT USE ONLY w - <br /> PHASE I DATE ' <br /> ITPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> :INSPECTION BY f- DATE �� 7 INSPECTION BY DATE z� <br /> EH 14 .26 Rev. 9/ _ .�f:9 78 =`2M <br />