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SAN JUAQU1N LUCAL HLALIH =1 IKILI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. L <br /> Telephone: (209) 466-6781 <br /> -# APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued y' <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 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/D CITY/TOWNZ.-cr4- <br /> Owner's Name Z'x J X Phone G y q L� <br /> Address City <br /> Contractor' s Name License# Phone E�2 F? —,S- <br /> IS <br /> SSIS CERTIFICATE OF WORKMAN'S COMPENSATION ItSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION C3DESTRUCTION❑ W <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPRL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINiO�PRIVATE DOMESTIC WELL_,X� PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 'f <br /> Domestic/private Drilled Dia. of Well Casing �, -•__,,, <br /> Domestic/public Driven - . Gauge of Casing 7Ao i P Ue <br /> Irrigation Gravel Pack Depth of Grout Seal T 5p <br /> Cathodic Protection _Rotary Type of Grout 130M Zon <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.p, <br /> PUMP REPLACEMENT: CIState Work Done <br /> PUMP REPAIR: Q 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 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 C OR A G OUT INSYQCN OR TO GROUTING AND A FINAL INSPECTION. -0 <br /> SIGNED TITLE: ZaEw I DATE:- �d <br /> W PLT TLTNT ON REVS S ID <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE y '.41'7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE_Y -l2 - 7� INSPECTION BY DATE—��`7® <br /> T •. <br /> EH 1426 Rev. 12-77 <br />