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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7--jd g'7 <br /> Telephone: (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/,o-j,/-7g- <br /> This <br /> ssued/,ol,/-7g"This Permit Expires I Year From Date Issued <br /> Complete In Triplicate) — ; w'lfV�71&t( <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 /> ,oaQuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. f y f w rZs <br /> EXACT STREET ADDRESS CITY/TOWN_ � s,�/ <br /> Owner' s Name 1 c4o faz4 S rJ Phone S'97 - 2-1 1 <br /> Address 7 -3 6, Fv+ A r:c City . <br /> Contractor's Name Li cense#__y�'7s—Phone 9 9-.3 _- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL L f DEEPEN'❑ :"- RECONDITION ❑ DESTRUCTION❑^ Y <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 N <br /> PUMP INSTALLATION J4 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY [j <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 Installed by: <br /> PUMP INSTALLATION: Contractor V4 .S zrrr; �,�C,0 <br /> Type of Pump .StJL bads" Iii e,e-c H.P. <br /> a S <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: &A J DATE:f/ 7, <br /> DR W PL T PLAN ON REVERSE IDE <br /> PHASE I <br /> FOR DEP RTM NT USE ONLY <br /> n <br /> APPLICATION ACCEPTED BY L DATEl4 7 e <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE Ilb ONAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7? <br /> EH 1426 Rey, 12-77 J 1�W 2M <br />