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y SAN JOAQUIN.:,LOCAL HEALTH DISTRICT <br /> R-.-OFFICE USE: 1601 E. Hazelton;:Ave,..> Stockton, CA 95205 Permit No. 7�-�.��s' <br /> .r <br /> Telephone--.- ('209) 4667,6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - � <br /> This Permit.-E.x ires; l ,Year From-Date Issued <br /> J. 12 f ' Complete In Triplicate <br /> Application is hereby made to the San Joaquin:'Local� Health District for a permittto' construct <br /> and/or ''install' the`work 'her`ej n described,, This,application -is 'made in comps i anc6 with San , . <br /> Joaquin County Ordinance' No![ 1862 and the'-Rules ;and- Regulations of the- San Joaquin .-Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN ` <br /> f Owner's Mame Phone ' !VG�Z- 21)6, <br /> Address city <br /> Contractor' s Name License# ? /1�/ Phone <br /> me&1,_ <br /> IS CERTIFICATE OF WORfflAff S SCO"MPBSATIOP! IPISUR "IC'E"ON FILE"VIITH SJLHD?- YES NO <br /> TYPE OF WORK (Check) : NEW TELL 0 D�, RECONDITION ® DESTRUCTION[) <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 <br /> PUMPI.INSTALLATION E3 PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK�SEWER LINES�� _PIT PRIVY <br /> SEWAGE DISPOSAL LDr� C SSPOOL/SEEPAGE PIT �--- OTHER--- <br /> PROPERTY :LINV6,!4PRIVATE DOMESTIC WELL S4±1 PUBLIC DOMESTIC WELL <br /> �--- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Z <br /> _Domestic/private Drilled .Dia. 01 Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel—Pack— i Depth of Grout Seal <br /> Cathodic Protection V_Rotary . Type of Grout <br /> Disposal Other Other Information -- <br /> Geophysical Surface Seal Installed by: ,� _ <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done »~ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana PrRe ure <br /> I hereby certify that I have prepared this application and thaf the work will be done in acco.rdanc <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-perforrance- of the.-work. for which this permit .is issued, I shall <br /> k 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 C <br /> , ;,ROUT/-JNSACXON PRIOR TO GROUTING AND A- FINAL INSPECTION. j <br /> SIGHED - TITLE: DATE: Z � <br /> (DRAW PLOT PLTN ON REVER E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' , <br /> I APPLICATION ACCEPTED BY DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-rtINSPECTION PHASE <br /> _U1 FINAL INSPECTION = <br /> INSPECTIQN BY DATE INSPECTION BY <br /> ' cu I A Oc o,;.: ,�°.�?. 1178 �" 2M <br />