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/ SAN JOAQUIN LOCAL HEALTH DISTRICT_EOR ' <br /> FFICE USE: ✓ 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No._70_1,4� <br /> Telephone: (209) 46676781 <br /> Date Issued/o <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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. r <br /> EXACT STREET ADDRESS .3l�a 2- � ��� CITY/TOWN / A0 <br /> Owner' s Name AJ., ,r� / Phone <br /> Address' /3 G� l Je 7' . . _ <br /> City Q. O <br /> Contractor's Name <br /> License#, Phone .S"f�— <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATIO"i INSURANCE ON FILE WITH SJLHD? YES , NO <br />.__T_ YPE. .OF._WORK (Check) :t NEW-WELL 0---'- DEEPEN [2: 14 . REC.0NDITI-ON-CD 7-�-_DEST-RUC'-ION-[ <br /> WELL CHLORINATION [3 WELL ABANDONMENT 0 OTHER 0 �4 <br /> PUMP INSTALLATION WL PUMP -REPAIR❑ PUMP REPLACEMENT Q <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal' Instal ed by: <br /> PUMP INSTALLATION: Contractor H 3 <br /> Type of Pump <br /> I` PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> iDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr-i-be,Mater i a -man 2-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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE: DATE: <br /> DRAW PLOT PLTN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> '[ APPLICATION ACCEPTED BY Izi "0_^� DATE U �� <br /> ' ADDITIONAL COMMENTS: Z4 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE G O f <br /> Pu 1a9A Qn., ` 19-77 _ . 1 78 2M- <br />