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CoTFICE <br /> 1a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued `7 <br /> ('Complete In Triplicate) <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. 1862 and the Rules and Regulations of the San Joaquin Local health ' <br /> District. <br /> EXACT STREET ADDRESS _A0 k A a S. �+. ,�-� m r1 .L� CITY/TOWN SSu� <br /> Owner's Name #r rC,eo v�s �-c Phone <br /> Address a 3 Y 000 City C.,T01,44— :.. <br /> Contractor's Name boa License Phone 5&2—a <br /> r5 CERTIFICATE OF WORKMAN'S CO";PE. SATION INSURANCE ON FILE WITH SJLHD? YES X NO" <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION d DESTRUCTIONEn <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 �R <br /> PUMP INSTALLATION C7 PUMP REPAIR PUMP REPLACEMENT Q p� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ... PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLI DDOMESTIC 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 /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump < H.P. 6� <br /> PUMP REPLACEMENT: Q State ,Work Done <br /> PUMP REPAIR: Gg 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 Sart Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. dome 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 CAL FOR A GROUT INSP ON P GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: <br /> D L ON REVERSE SIDE <br /> PHASE I <br /> PARTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED B 2A DATE d <br /> ADDITIONAL COMMENTS : <br /> /_74,*� <br /> PHASE II GROUT INSPECTION P SE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �a <br /> EH 14 26.'Rev. 9/7 9(7-8-' 2M'_ , <br />