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a <br /> SAN JOAQUIN LOCAL HEALIH DiS [RICI <br /> FFICE SE: 1601 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No.7 - 74 <br /> R Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -a 7[� <br /> This Permit Expires 1 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 <br /> and/or install the work herein described: This 'app'lication is made in compliance.with San <br /> JoaQui n County Ordinance ,No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distric,. <br /> EXACT STREET ADDRESS" �� G �. �[� CITY/TOWN 60 'J <br /> I <br /> Owner' s Name /�i`� C Phone <br /> Address City <br /> Contractor' s Name s ems+ 1"m Of'h License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTIONED <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHE <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r' <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 by: <br /> PUMP INSTALLATION: Contract&r• ,:S' <br /> Type-;of' Pump S H.P. f <br /> PUMP REPLACEMENT: 1[],State Work Done <br /> PU IR:- Q State Work Done <br /> D STRUCTION OF WELL: Well Diameter 47 L0 tV4—t— .- Approximate Depth 84 <br /> Describe Material nd Procedure <br /> I hereby certify that -4 have prepared this ap'pl'ication 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 <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED c TITLE : DATE: —7 <br /> ��DRW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE7-Z(./- <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION VPHASE II 'INAE INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATES Zd <br />