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SAN JOAQUIN LOCAL HEALTH 015-FRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2 9 - -35 3 <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued r d <br /> Thals Permit Ex i res1 Year From Date Issued <br /> � t <br /> Complete In Triplicate Lv_ <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> and/or i..nstall the work herein described. This application is made in compliance with San. <br /> loanuin County Ordinance.No. 1862 and the. Rul-es' and Regulations of the San Joaquin Local Health I <br /> District. <br /> EXACT STREET ADDRESS Z Z d-z?e °-r I CITY/TOWN i a� <br /> Owner' s Name k-r_o✓ 0 Ilk' o,v Phone �f- 36 7 _ <br /> Address z corms U City <br /> Contractor' s Name p�N�,�__ _ _ <br /> License# Phone <br /> IS CERTIFICATE OF WORKMAN'S CF0MPENSATIO"1 'INSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELIL❑ - DEEPEN ❑ RECONDITION Q DESTRUCTION[) <br /> WELL CHLORINATION pWELL ABANDONMENT [] OTHER 0 <br /> .I�I� <br /> PUMP INSTALLATIONPUMP REPAIR 0 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 Tools Dia. of Well Excavation F <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ''*,Driven .. : -Gau.ge.of-Casing; . <br /> Irrigation i Gravel Pack Depth"-of Grout Sea <br /> Cathodic Protection Rotary- , ,, r Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: _ <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump _ �' �, -- - —._ H.P. 3 t <br /> f <br /> PUMP REPLACEMENT: jI State Work Done <br /> is <br /> PUMP REPAIR: Q State Work Done - ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � � 1 <br /> I hereby certify that I have ,prepared this application and that the work will.fbe done in accordance <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations ofthe San Joaquin Locall <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,Aorkman's Compensation <br /> laws of California." i <br /> I WILL CRL OR G T INSPECTION PRIOR TO GROUTING ANDA F ALAINSPECTION. <br /> SIGNED TI7LE DATE: <br /> �1DR W PLOT PL N°'ON REVERSE SIDE <br /> II FOI?_ EPARTMLNT USE ONLY <br /> PHASE I .` <br /> APPLICATION ACCEPTED BY ZJ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-.INSPECTION PHASE III FINAL INSPECTION <br />,` INSPECTION BY ' DATE / AV INSPECTION BY DATE <br />�Fp 149A Dell► 2M ,j <br />