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.N r <br /> 4. SAN JOAQUIN LOCALr4EALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haze1ton�4ve. ,-%Stockton, CA 95205 Permit No. -70/ <br /> Telephone: ,-- (2097 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> -AT-7 <br /> This Permit. Exp i'res' 1"Year From Date Issued <br /> is Complete In Triplicate <br /> Application is hereby made to ;llthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. This application is made in compliance with San a <br /> JoaQuin County Ordinance No. 1862 and the -Rules and Regulations . of the San Joaquin. Local. Health <br /> District. [ )aC + <br /> EXACT STREET ADDRESS n . <br /> t f ;I a 1 r1 C_n onRdhL }�`� m' !�" CITY/TOWN Trac = 4 <br /> Owner' s Name Phone <br /> Address i d . - City Y- . ' <br /> Contractor's Name I t�Ylhi License# C) l3 Phone 5413 <br /> -C, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELLU:a- DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ c�k <br /> DISTANCE TO NEAREST: SEPTIC`rTANK10-Q` 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 F Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 ✓Drilled Dia. of Well Casing ;," P yc� <br /> Domestic/public � Driven Gauge of Casing <br /> Irrigation i i,,- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection It ,/Rotary Type of Grout C Ft <br /> Disposal I Other Other Information Sa L 0� r)E # <br /> Geophysical t Surface Seal Instal ed by: Dv'O -r 1 <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descri-be 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 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 AND A FINAL INSPECTION. <br /> SIGNED A-r)n1 L4,S S. + 1 0 C. TITLE: - . DATE: (D --X) - <br /> LJ 1-/ (DRAW PLT PLAN ON REVERSE SIDE <br /> FOR DEP RTM E ONLY <br />` PHASE I <br /> IAPPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPEC BY C. ATE/O,CU 1AOC <br /> �6 1W7 9 W A r -- <br />