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r SAN JOAQUIN LOCAL HEALIH DISIRIC1 <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g_/moo-t1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> Aoolication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> aild/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> .;' strict. <br /> i <br /> EXACT STREET ADDRESSQ��y CITY/TOWN <br /> - S <br /> Owner's Name Phone <br /> Address �S A "ILL City G��/Q.�E3a] ' <br /> T ; <br /> Contractor' s Name1 D, $t1 j« 2) License_2 Io Phone P$ <br /> 'S Cr RTIF'Ct1TC OF WORKr'ANIS C0"1PrNSATI'O1,!`'Ik,SURA'1CC ON FILE WITH SJLHD? YES '10 <br /> T1'pG` QF ,dORK '(Check) : NEW WE'Lb LDEtPtN O---RECONDITION'-[]--DESTRUCTION(] <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR IM 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 /> "Iridustri al - --CabTe Tool- Dia. of Well Excavation <br /> Domestic/pri.vate f :. Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing- <br /> Irrigation <br /> asingIrrigation Gravel Pack - Depth of Grout Sea <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 N.P. <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: Mtate Work Done , <br /> DESTRUCTION OF WELL: Well Diameter - Approximate 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 this permit is issued, I shall I <br /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> laws of California. " ' <br /> I WILL CALL-WR A GROUT IUSPECTION PRIOR TO GROUTING AND,4 FINAL INSPECTION. <br /> SIGNED TITLE:. DATE. �o22"�GQ <br /> W -PL L N ON REVERSE SIDE <br /> R DEPARrENT USE NLY ' <br /> PHASE I <br /> PPLIC TION ACCEPTED BY DATE 7 :?/Z-ZLE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I I `NAL INSPECTIO <br /> INSPECTION BY DATE' INSPECTION B DATE 7S <br /> FH 1 d7F, Da 1077, oe - . n.. <br />