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SAN JOAQUIN LOCAL` FitALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No.7,3_1375' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit .Ex i:res.. l Year From Date Issued <br /> Complete I.n ,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 /> � r <br /> EXACT STREET ADDRESS. Zia <br /> �J CITY/TOWN <br /> b <br /> Owner's Name - Phoney-g2/ <br /> Address City��,k���, <br /> Contractor' s' Name LicenseiWLiq Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN TNSURd. QE ON FILE WITH SJLHD? YES i40 <br /> TYPEOFWORK (Check) NEW WELL Q _. DEEPEN 96 :RECONDITION ❑ DESTRUCTION( <br /> WELL 'CHLORI-NATION CI-T WELL, ABANDONME-NT Q-,-- OTHER-1:] -- - --4—L, <br /> PUMP. INSTALLATION-0- `, PUMP REPAIR'Q PUMP---REPLACEMENT-M J> I <br /> DISTANCO TO NEAREST: SEPTIC TANK_<o SEWER LINES$_a(� PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPPGE PIT OTHER -� <br /> ' PROPERTY LIN9Q.4PRIVA�ESTIC WELLZO .k_ PUBLIC DOMESTIC WELLar-- <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS .s <br /> Industrial ': Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing `� <br /> t Dame�sti c/publ i s Driven Gauge, of Casing J u n a <br /> ..Irrigation` Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information �—. }� <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLAThON: ; Contractor ' <br /> y ' ` Type of'- Pump _ _ H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: , s Q State Work Done <br /> DESTRUCTION OF: WELL: ' Well Diameter Approximate Depth <br /> Describe Material an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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: 1 <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 annex as to become subject to Workman's Compensation, <br /> laws of California. <br /> I WILL CALL FOR AGGRO I PE I ,TO GROUTING AND A FINAL INSPECTION. <br /> SIGHED TITLE: AgiDATE: <br /> �. DR W, PLOT L N 'ON REVE S IDE <br /> w.. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4PPLICATION ACCEPTED BY "cam- D TEX7gr <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION Y DATE 5_-1-4' <br />:H 1426 RPU 19-77 <br />