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SAN JOAQUIN •LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton ,Ave.,, Stockton, CA 95205 Permit No.7 :2_-j 6 p ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3; <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In .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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �. / o CITY/TOWN STJ CA' �_ <br /> Owner's Name b jO WA rJ9 81 T S?a (AW Phone -: <br /> Address. 300 &r /t/ l OZ30 fd rGUd4• City <br /> Contractor' s Name<'L. A4 �)C-L , F P , Li cense# 046 Phone lUnW <br /> IS CERTIFICATE OF WORKtiAN'S COMPENSATION INSURAINCE Ofd FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> industrial Cable Tool ....-Dia. of Well Excavation ' /z� <br /> Domestic/private Drilled Dia. of Well Casing d'4' <br /> Domestic/public Driven Gauge of Casing *fll/l <br /> Irrigation Gravel Pack Depth of Grout SealJV I <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 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 /> 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 G%MT I SP TION PRIOR TO GROUTING AND A FINAL INSPECTION, l p <br /> SIGNED TITLE: Qw DATE: 3—/ —7 <br /> ... ..-ADRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 14� <br /> PHASE JI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r-z-4Z <br />} EH 1426 Rev. 12-77 1/7 M <br />