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SAN JOAQ IN "LQCAL HEALTH DISTRICT <br /> OFFICE_ USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ]q -561 <br /> i Telephone: (209) 466-.6781 <br /> � Date Issued 6L 114 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 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. r � <br /> EXACT STREET ADDR S L pT ` S CITY/TOWN <br /> V s�raame -1Phon �- <br /> Address .�: ttCity @ <br /> v ii 1 <br /> Contractor's Nam License iPhoneihs-&-�a'lob <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO'N TNSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN E] RECONDITION Q DESTRUCTION[] cam' <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 w <br /> PUMP INSTALLATION l&I PUMP REPAIR D PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK ,2g! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD A;R' CESSPOOL/SEEPAPE PITii OTHER <br /> PROPERTY LINE7� PRIVATE DOMESTIC WELLLaC___ PUBLIC DOMESTIC W—ELL7�=:—:-4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable Tool Dia. of Well Excavation113 1 <br /> Domestic/private Drilled Dia. of-Well Casing -" ` <br /> _. v_. . <br /> Domestic/publ i c Dffven— Gauge of-Cas i rig, <br /> Irrigation- : 7Y Gravel Pack Depth of GroutSeal r <br /> Cathodic Protection . Rota Type of Grout'- <br /> Disposal the _Other, Information <br /> Geophysical Surface Seal Installed by ij a—& V,, n,in__ <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP` REPLACEMENT: State Work Done } <br /> PUMP REPAIR: Q State Work Done j <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Y <br /> Describe Material and Procedure.— <br /> �r <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. ,Sdn Joaquin Local <br /> Health District. Home owner or-licensed- "adent' s signature—certifies the following: <br /> "I certify that ,in the performance of the. work for which this permit js issued,- I shall <br /> not employ any person in such manner as­toibeC6ie subject to Workman's Compensation <br /> laws of California. " -- _ .• <br /> I WILL CALL FOR A GROUT INSPECLI-ONyPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r TITLE: DATE.: <br /> DRAW PL T PL N ON REVERS ' SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 71 DATE <br /> ADDITIONAL, COMMENTS : <br /> PHASE II GROUT INSPECTIONi PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 /'7Q 7M <br />