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SAN JOAQUIN LOCAL HEALtH UISIKICI <br /> OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 gr-Zl <br /> uJ Telephone: (209) 4�66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �3 2 <br /> This Permit Ex ires 'l Year From Date Issued <br /> Complete In Triplicate ZQ -j ?0 r�/, <br /> 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 San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health <br /> District. NY/ TOWN <br /> EXACT STREET ADDRESS -�� <br /> Owner's NameAt Phone <br /> Address City <br /> Contractor' s Name Li cense�,S?3lZ_ Phone + <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"d I"aSUR rF ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL[I DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ N <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN�� SEWER LINES,1�-,)l-f P6--PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT , OTHER— <br /> "PROPERTY <br /> PROPERTY LIN 04PRIVATE DOMESTIC WELD# 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 5eal Q4r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by. <br /> PUMP INSTALLATION: ContractorALL VIP <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: ❑State Work Done or <br /> PUMP REPAIR: O 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 GAL OR A G UT I E 0 IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (QWW PLOT PLAN ON REVE S IDE <br /> FOR DEP RTME T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 8' S <br /> ADDITIONAL COMMENTS : <br /> PHASE 1J GROUT INSPECTION PHASE IIJ INALNSPECTION <br /> f INSPECTION BY f, DATES 7&f INSPECTION BY DATV,,--�,:�-7,' <br />_EH 1426 - Pay- 19=17____ _ _____ l� 2M_ <br />