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SAN JOAQUI:N :LOCAL--.HEALTH DISTRICT <br /> FnR QFFICE USE: 1601 E. Hazelton Stockton, CA 95205 Permit No. _ <br /> V:Ave,_,, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S-,13-2 <br /> This Permit Expires I 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 f <br /> and/or install the work herein described. This application is made in compliance with San, a <br /> .'oaQuin •Courty Ord-finance No. :1862 and the Rules and Regulations of the San Joaquin Local .Health <br /> District. �cP .��L �9 . <br /> EXACT STREET ADORES CITY/TOWN <br /> Owner's Name Ph'oneya�-'a CC <br /> Address <br /> ct2l , Ci ty. <br /> Contractor's, dame License#�gDdl� Phone — r <br /> IS .CERTIFICATE OF 1dORK�tAr `S COFIPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL[ `] DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES-J//� 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 /> _ - X _Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation _Gravel Pack Depth of Grout Seal . f <br /> Cathodic Protection �_Rotary ' Type of Grout <br /> Disposal Other Other Information �� , --,,J _ <br /> Geophysical Surface Seat Installed b , <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate' Depth' - <br /> Describe Material and Proce ure <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 y <br /> laws of California. " <br /> � <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED /4 `/}7. TITLE: • DATE: g <br /> DR W PLOT PL ON REVERSE SIDE <br /> FOR DEP R MENT USE ONLY <br /> PHASE I <br /> 4PPLICATION ACCEPTED BY DATE <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY DATE <br /> H00 K ., .- -3-1- ` <br />-H 1426 , Rev. __._ ,�+-�� h,• k <br />