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SAN JOAQUIN LOCAL -HEALTH DISTRICT ' <br /> FFICE USE: 1601. E.. Hazelton Ave-:., Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued $r,7�T <br /> This Permit Expires 1 Year From .Date Issued <br /> g Complete In TriplicateT I , <br /> Application is hereby made to :the San Joaquin Local Health Distr.ict: fo r a permit to construct.. <br /> and/or install the- work hereinLldescribed=. Thin-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 /> F ` <br /> District. <br /> EXACT STREET. ADDRESS <br /> CITY/TOWN a <br /> Owner' s Name LU-Cz�- Phone 3 5 <br /> Address �q7 S4-) City j <br /> Contractor' s Name , �C Licensee,a/ Phone <br /> I ,! <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURA!' E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Ci DEEPEN 0 RECONDITION ® DESTRUCTION❑ � <br /> { } WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 - <br /> f PUMP INSTALLATION S— PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTAqCE TO NEAREST: SEPTIC:TANK �� SEWER LINES lel& PIT PRIVY <br /> SEWAGE DISP SAL FIELD --- CESSPOOL/SEEPAGE PIT OTHER <br /> #: PROPERTY LINES''PRIVAT DDOMESTIC WELL AL— 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 /> rrigaIion - I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A Rotary ,� � � Type of Grout <br /> cebisposal a `.' Other _ Other Information <br /> :-Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor PM <br /> Type ofd Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> w � <br /> PUMP REPAIR: Q State Work Done - <br /> DESTRUCTIONcOF`WELL:- •Well Diameter Approximate Depth <br /> Descri t;e Materi a I and Rroce 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. -Homeowner or-licensed'agen=t'.s'signature certifies the following: <br /> "I `cer�tify that in the performance of the-work for which this permit ' is issued, I shall <br /> Ir not employ any person in such manner as to become subject to Workman s Compensation <br /> laws -of'California. " =� <br /> I WILL CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. r <br /> SIGNED¢ TITLE: &4-1%.<-r. DATE: 7 <br /> DR W PLOT PLTN <br /> ON REV RSE 104 <br /> SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE ii. TE <br /> APPLICATION ACCEPTED BY <br />,ADDITIONAL COMMENTS: r <br /> -PHASE-IT GROUT -INSPECTION - PHASE II NSPECTION <br />�INSPECT-ION_8Y._-- -r ..-- --DATE � -� ��': ' = INSPECTION-BY DATE 1zo- <br /> _7_ <br /> ACV 7 A7G fl..., I- U 2M <br />