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SAN JOAQUIN b0*L,1EALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 _3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ -? <br /> This Permit Expires 1 Year From Date Issued <br /> Coinpl ete In Triplicate 2-13 - 102,0 -2-/. <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 /> ,:oagtin County Ordinance No. 1862 and the.:Rules . and. Regulations of: the .San .Joaquin Local Heal <br /> District. "rj-f"� `^r <br /> (���7�I f S off- ' f <br /> EXACT STREET .ADDRESS �� � <br /> �. Q ITY/TOWN <br /> 01?Owner's Name Phone <br /> Address k-00 _ .-. - _. City <br /> Contractor's Nam icense# Phone <br /> Aeb <br /> IS CERTIFICATE OF WORKMAN S COMPENSAYi0111 IN RANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECON'DITION ❑ ' ' DESTRUCTION❑ h� <br /> WELL CHL INATION ❑ WELL ABANDONMENT ❑ ' OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ ; <br /> DISTANCE TO NEAREST: SEPTIC TANK //Z2/k SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA —FIELD CESSPOOL/SEEPAGE PIT OTHERl)e&-025 <br /> PROPERTY L-INE -. PRIVATE DOMESTIC- WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL'' ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ` f"' Cable Tool�:- Dia. -of. e1,1_Excavati on <br /> Domestic/private Drilled ', 'Dia. of Well Casing/ <br /> __Domestic/public Dri-ven Gauge of Casing FA6Q 4V ' <br /> Irrigation' =Gravel Pack Depth of Grout Seal - <br /> Cathodic -Protection Rotary Type of Grout <br /> Disposal i. . Other Other-Information i <br /> Geophysical Surface Seal Installed- by: <br /> F <br /> PUMP INSTALLATION: Contractor "` ' -.4 r <br /> Type of Pump _ H.P. <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 /> s <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 this permit is issued, I shall <br /> not employ any3-person in such manner as to become subject to Workman 's Compensation <br /> laws of California." <br /> I WILL CAL FOR A-6;RO INSPECTION RIO 0 GROUTING AND A FI L . INSPECTION. <br /> SIGNED TITLE: DATE: <br /> _(DRAW PLOT PL ON REVERSE D <br /> FOR DEPAPMENT USE ONLY f j <br /> PHASE I r <br /> APPLICATION ACCEPTED BY ` _ DATE �? <br /> ADDITIONAL COMMENTS : Z <br /> PHASE IL OUT INSPECTION -pHA, III FINAL INSPECTION 1 <br /> INSPECTION BY27- DATE INS ECTION B _ DATF 2 152 <br /> wR o K. r <br /> EH 1426 R - 7. . . [ �n�,�r �. . . <br />