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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. —a/ 7 <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This ,Permit Expires 1 Year -From Date Issued i <br /> Complete In Triplicate <br /> ,Application is hereby made to the San JoagU.in 'Loc'al Health District for a permit to construct <br /> and/or install. the work her ein► 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" S s'a' 6JQv A/A CITY/TOWN i <br /> Owner's Name ,r-___ c �'_ ch ..Phone <br /> , i <br /> Address f?0 Cit ` <br /> y l?Z%t>�ae� L" 1 �- <br /> Contractor's Name '�i7 License# ! 77.,A-7hone_ y /i�?!a <br /> IS CERTIFICATE OF WORKMAN'S COMI SA IO INSURANCE ON FILE )^WITH SJLHD? YES )< 740 i <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [2 DESTRUCTIONE2 <br /> WELL CHLORINATION D WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR($) PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC :TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WEL'L­ CONSTRUCTION SPECIFICATIONS <br /> Industrial ICable 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: Contractor <br /> Type of Pump y H.P. <br /> �J <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: (@State Work Done d � � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material amd Proce ure p <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. 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 INS TIqV ymftNTO GROUTING AND A FINAL INSPECTION. <br /> SIGN 0 TITLE: DATE: <br /> DR W PLOT PL ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY 4 DATE 7 } <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PH IYVFINAL INSPECTION <br /> INSPECTION BY DATE � .� INSPECTION B DATE FZ <br /> EH 1426 Rev_ 32-77 1 17A, <br /> W <br />