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a <br /> SAN JOAQUIN LOCAL HEALTH D1STRIU1 <br /> MOE OFFICE U E: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> rfi <br /> This Permit Expires 1. Year From Date Issued <br /> Complete I'n 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 />,'oanuin County Ordinance No. 1862 and the. Rules- and Regulations of the San Joaquin Local Health <br /> District. <br /> i <br /> EXACT STREET ADDRES (_ CITY/TOWN <br /> Owner' s Name 2 Phane �-t' <br /> Address ' <br /> � ,,. C i ty CSC <br />.Contractor' s Na ;s J'/ AGF Li censefj�.? Phone �f <br /> 1 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE' OFRWORK (Check) : NEW WELL 99W,I DEEPUZRECONDITION ❑ DESTRUCTION[� <br /> J <br /> WELL CHL I WELL ABANDONMENT ❑ OTHER 0 � s <br /> PUMP INSTALLAT N L; PUMP REPAIR❑ PUMP REPLACEMENT C] Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERil <br /> PROPERTY LIME -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 6omestic/private Drilled Dia. of Well Casing ! <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical Surface SeIA Installed by: <br /> PUMP INSTALLATION: Contractor �S /��, ��4llC_0E <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 i <br /> A <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'yagent' 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 alifornia. " <br /> I WILL CAL OR A G 0 T LNSPECTIOVPRI09 TO„ GRGUTING AND kdNAL INSPECTION. <br /> r <br /> SIGNEDTITLE : DAT ' <br /> P OT PLAN ON REVER DE <br /> FORD ARTMENT USE ONLY <br /> PHASE i /� � <br /> APPLICATION ACCEPTED BY d DATE J 76c--_ <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION 'PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,&0 DATE`? <br /> 714 1A99 Unu ' 17_77 -z f-To 0 <br />