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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FILE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.' 9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT date Issued <br /> " (Complete In Triplicate) <br /> `,�-!` ^ `L( 4 <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..�1.8.62 and, thd Rules and Regulations of the San Joaquin Local Health <br /> District. oVS - 0- .: t-t.s -F(w y ..7..I k <br /> EXACT STREET -ADORE.S I S Ed. CITY/TOWN S-rinc-tc-70-i <br /> Owner's Name Aq cr,� S lac. Phone 3 -3 1— <br /> Address 5-;-o —20 ToST. City <br /> Contractor' s Name <br /> License �fl�f - Phone i <br /> IS CERTIFICATE- OF WORK'iAN'S CO"�PENSATION I SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL X --- DEEPEN [] RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHERf� + al ; <br /> . PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST: SEPTIC TANK D', SEWER LINES r . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�D�r. CESSPOOL/SEEPAGE PIT -- OTHER ` h <br /> PROPERTY LIN16-4PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private -�-Drilled Dia. of Well Casing n1 <br /> Domestic/public Driven Gauge of Casing & 06 <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 b w c # <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ElState 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 accordant <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 /> "? certify that in the performance of the work for which this permit is issued, I shall <br />'t not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California . " <br /> i`. I WILLCALL FOR A GROUT I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> DATE: Z,Al <br /> SIGNED TITLE: f-' <br /> DRAW PLOT PLAN ON REVER SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE p <br /> APDL 7CATION 'ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS : <br /> PHASE II OUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY DATE / %7 <br /> 5/ 9 Ai <br />