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SAN JOAQUIN_LOCAL HEALTH DISTRICT <br /> OFFICE,USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. -Y- <br /> Telephone: (209) 466 .6781 7 <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 Local Health District for a permi..t to construct <br /> and/or install the work herein described.! This, app,lication is made in with San <br />,'oanuin County ordinance No. 1862� and the Rules and Regulations of- the San Joaquin Local Health <br /> Distr'ct. r <br /> EXACT STREET ADDRESS 6u, t7Y�� ' � '� CITY/TOWN <br /> Owner' s NameS�? --- Rhone <br /> Address eC-:4 > City . <br /> Contractor' s ..Name / LicenseA � 333Phone <br /> IS CERTIFICATE OF WORKMAN'S COM ENSATIO'N INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF-WOR:K (C-hec--k)-:-- NEW-WELLL-_- `DEEPE'N'p" " RECONDITION [nom^DESTRUCTION[) �v <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: MIState Work D <br /> PUMP REPAIR:` ❑State Work Done <br /> DESTRUCTION OF WELLY'-, Well Diameter te`Depth '""` <br /> Describe Material and Procedure <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 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 ..th'is 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 AND A FINAL INSPECTION. <br /> SIGNED TITLE: A'P.— .�,4 � DATE: C5 �f ?Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> -i FIOR,DEPARTMENT USE ONLY <br /> PHASE I �'; ': <br />'APPLICATION ACCEPTED .BYak.z�yz � A 'r- - <br /> DATE L-1-Z6 <br /> ADDITIONAL COMMENTS, �',J �=rc ; <br /> PHASE II ''GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE " ``"� : INSPECTION BY DATE_ f�j' <br />