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€ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r.!f�FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,,C <br /> Telephoner (209) 466-6781 Ae <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �3-�s <br /> This Permit Ex ir.es 1 Year From Date Issued <br /> ' (Complete .In Triplicate ; <br /> Application is hereby made to the San Joaquin Local - Health District for aermitt ' <br /> and/or install the work herein-described. This application is• made in compliancewithnSan <br /> uct <br /> Joaquin County Ordinance No.' 1862 and the Rules and Regul'ati s of the San Joaquin Local Health <br /> District. II /. <br /> EXACT STREET ADDRESS I--K X V , n CITY/TOWN <br /> ' Owner's Name- 7S-I? <br /> .!" • <br /> Phone--. — <br /> Address <br /> Contractor' s Name ter' �^ License# �' o Phone 63 ;e.v/6 <br /> IS CERTI------------ <br /> FICATE OF WORKMAN'S COMPENSATION INSURANCE ON 1=ILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION DESTRUCTION[ O <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHERI::) oA <br /> PUMP INSTALLATION T?�. PUMP REPAIR 0 PUMP REPLACEMENT [ +� <br /> DISTANCE TO NEAREST: - SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT <br /> INTENDED US <br /> E" � TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - a Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation x Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ` _ .. ---Surface Seal -Install d-b l <br />--PUMP-I- ST -LAT-I.ON: ­Contracto•w� r% <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: Q State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Descri'6e Material an2 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 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 6-Fi TITLE: DATE: ! <br /> MPAQ PLT L N ON REVERSE SIDE i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY fel DATE — S�-72 <br /> ADDITIONAL COMMENTS: - ---- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE i!/ INSPECTION BY DATE = , <br /> EH 1-426 Ram 1"277" 1 ,7 <br />