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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Z6 <br /> Telephone: (209) .,466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 here-in described. This application is made in. comp-liance with San <br />,oaQuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr4ct. <br /> EXACT STREET ADDRESS r � CITY/TOWN 2grS� 3C04.,, <br /> Owner's Name Phone 8 <br /> Address. City �SCL�, . <br /> Contractor' s Name ; .a/ Licensefg2&& Phone r 0 <br /> IS CERTIFICATE OF WORKHAN'S `641PENSATIOIN INSURANCE ON FILE WITH SJLHD?. YES. <br /> - _TI_ _ _ .•_ _� _.777 , <br /> TYPE OF WORK #(•Check) : NEW WELL 0 :DEEPEN 0 RECONDION =[ DESTRUCTIO- :�.:terN:—❑ � <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ <br /> 'PIJMP-I.�STALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT kr <br /> � f <br /> DISTANCE TO NEAREST: SEPTICi`TANK SEWER LINES'�: _e PIT PRIVY <br /> OS <br /> SEWAGE' DISPAL FIELD I CESSPOOL/SEEPAdC-PI_T_. OTHER <br /> ' PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:--of 01AI EXcava:tion <br /> Domestic/pri vate _ _D.r_�.]J ed._ Da a_. of _We71.Cas i.ng_ 1 <br /> i c%public � i � Driven ���Gauge of Casing -Irrigation -1 Gravel Pack Depth of Grout Sea <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal fi Other Other Information <br /> Geophysical �� k Surface Seal Instal ed b <br />'UMP INSTALLATION: Contractor , g f -,\ <br /> Type of, Pump ss <br />'UMP REPLACEMENT: R State; Work Done {- <br />'UMP REPAIR: <br /> State Work Done I <br /> ESTRUCTION OFWELL . Wel T Diam•er <br /> Approximate Depth <br /> Describi!'Mi eria and Procedure— <br /> hereby <br /> roce urehereby certify that I have prepared this application and that the work will be done in accordance <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ealth 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. " l r <br /> WILL CA FOR A GR UT INSPECTION PRIOR TO GROUTING AND A FIN L INSPECTION. <br />[GNED <br /> TITLE: DATE: ,. ��-7 <br /> i DR W' PLOT PL N ON REV RSE SIDE 4 <br /> I.ASE I If 'FOR DE PA TMENT SE ONLY <br />'PLICATION ACCEPTED BY DATE ,� 7f <br /> IDITIONAL COMMENTS: <br /> PHASE II GROUT IN E CTI N� ,� <br /> SPECTION BY DATPHASE III FINAL INSPECTION <br />' " <br /> INSPECTION BY S� DATE <br /> 1426.__Rev- .12'-77 _ 3J <br />