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C'aht Ia � SAN JOAQUIN .LOCAL .HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. �J <br /> fll <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5 <br /> This Permit Ex I p i,res; 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 i'nst'all the work herein described.- This application - is made in compliance with San t <br /> Joaquin County Ordinance No. ° 1862 and- the Rules' and Regulations of the San Joaquin. Local Health <br /> District. A 1 J6� ,_r 4-P?. <br /> EXACT STRE T ADDRESS / p s�. s�.fa f�e .�9 /: CITY/TOWN <br /> ----.�—,�- � <br /> Owner's Name Phone <br /> Address �' l.`' Gity in <br /> Contractor's Name License# 74Mhone, 74 <br /> IS CERTIFICATE OF WORKMAN'S C PE SATIO'N I�aS53RAINCE"ON -FILE WITH SLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION Q DESTRUCTION <br /> TELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION G PUMP REPAIRCE) PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial 4 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 b : <br /> PUMP .INSTALLATION: Contractor <br /> 'Type of Pump H.P._ <br /> PUMP- REPLACEMENT: FIState Work Done r <br /> PUMP REPAIR: QState Work Done k,cssr� a ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana 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: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in4such manner as to become subject to Workman 's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPEC RIO TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE - ITLE: � DATE: <br /> W PLOT PLPN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ,.5 B <br /> APPLICATION ACCEPTED BY t/: Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A2 DATER <br /> CU 7Rhc o..: "io'_-7-7 1[78 _ 2M <br />