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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave' : ,- Stockton, CA 95205 Permit No. <br /> Telephone:_,- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> a This Permit .Ex ires -I Year From Date Issued <br /> Complete In Tri pl'i tate <br /> l Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is.made in compliance with Sa-n <br /> "oagain County Ordinance No. .1862 and the Rul and Regulations of the San Joaquin Local Health <br /> District. 0A `10�) <br /> EXACT STREET ADDRESS A72 ad . +—t ITY/TOWN <br /> Owner' s Name M i ,e-K — 4 k Ekk N 1 Phone <br /> Address City <br /> Contractor's Name S License# � Phone_ <br /> IS CERTIFICATE -OF�WOR-KHAN'S-COQ•iPENSAT-1O"J-l.t4S-URA"fC-EcOPI-=FILE 4JITFI SJtHD? ­ Y-ES---y NO - <br /> TYPE OF WORK ('Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION[) � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ 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 /> ,Industrial Cable Tool Dia, of Well Excavation - <br /> ___X `Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protect ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump--���= a ..1 -- s:V b �--- H. <br /> PUMP REPLACEMENT: ❑State Work Done <br />,P_UMP-mREPAIR: Y �_ .-;O.State_Work-Done <br /> .. <br /> DESTRUCTION OF WELL: Well Diameter _ Approxi-mate 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. "rt <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE:TITLE: DATE: O'ZO 7e <br /> DRTW PLOT PtAN <br /> ON REVERSE DE s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 0 <br /> ADDITIONAL_ COMMENTS: <br /> -''"- PHASE .II GROUT INSPECTION PHA FINAh INSPECTION <br /> INSPECTION BY F " , <br /> ." DATE__IVI INSPECTION 13(' <br /> DATVe <br /> EH 1426 'Rev. 12-77 . C 1 /7A W . . <br />