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/)I� SAN JOAQUIN LOCALHEALTHDISTRICT <br /> TOR OFFICE USE: 1601 E. Hazelton Ave Stockton, CA ' 95205 Permit <br /> I Telephone: (20.9.}.i'466-67;81. <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Date Issued <br /> This Permit Expires 1-Year From Date Issued <br /> Complete In Triplicate ; <br /> Application is hereby made to the San Joaquin LocalHealth 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. 1$62. and- .the; Rules sand. Regulations of the San Joaquin Local -Health j <br /> District. J,3 7 f c..c.:C-OG- C4P–.v�' o g7—Lf r�o- 7i { <br /> EXACT STREET ADDRESS ��T1` s It� CITY/TOWN� jdo� I <br /> Owner's Name ,v 26), hone 417 Zf 1 <br /> Address <br /> 2,h9 A— <br /> z.P r If- -City 7`rf <br /> Contractor' s Nameot/' License Phone !$f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! TN1 RA rr FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [] RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION 0 PUMP REPAIRC!5-- 'PUMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTICTANK"'-1 , SEWER LINES PIT PRIVY <br /> SEWAGE`�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE.,DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> - INTENDED USE TYPE OF WELL � : ="- <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection a Rotary Type of-Grout ,F <br /> Disposal t Other Other Information r <br /> Geophysical Surface _Seal Installed by: <br /> PUMP INSTALLATION: Contractor r 1 ' <br /> Type o Pump V �. H.P. I <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 hereb �certi f that 'I have 'R i <br /> y y prepared this application and that the work will be done in accordance; <br /> with San Joaquin CountyhOrdinances , State:Laws , and,Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed 'agent's signature certifies the fol"lowing: -" <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 AN A FINAL INSPECTION. <br /> SIGNED TITLEJ,' DATE;IQ / i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY y' DATE a <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B 9z3Yyi DATE <br /> EH 1426 Rev. '12-77 "'' .1/78 ' 2M <br />