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f <br /> SAN JOAQUIN LOCAL 'HEALI'H Ui5 FRIL I <br />=FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._71}- Y-3 <br /> Tele hone: y'- <br /> p (209) 466-6.78h <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5 -/a-?9 <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 f <br /> q ct or a permit to construct <br />[ and/or install the work hereiin described. This application is made in compliance with San <br /> luoaouin County Ordinance rdo. 1862 and the 'Rules and Regulations of the San -Joaquin Local Health <br />: Jistr�ct. <br /> EXACT STREET ADDRESSLZ.7, S' I <br /> S'f�.�L—�cl; _ CITY/TOWN . <br />(, Owner' s Name Phone <br /> S <br /> Address Ev City -s -, <br /> Contractor's Name .� License# �^ Phone_ -5�. aa7. <br /> --. <br /> IS, CFRTTFI-CATS OF WORKMAN'S COMPENSATION INSURANCE OM' FILEWITH--SJLHD? — YES _ - AVO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ® DESTRUCTION n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ED OTHER❑ <br /> PUMP ':INSTALLAT30N-:.0 PUMP REPAIR PT ' PUMP REPLACEMENT [� �77 <br /> DISTANCE TO NE-ARCST*:-----SEPT-IC'-T-AN1C`S-EWER-EINES---PTT`PRI-VY------------- <br /> SEWAGE;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V\' <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 Instilled b": <br /> PUMP INSTALLATION: Contractor <br /> —_._syp,e of Pump - H.P. <br /> PUMP REPLACEMENT: []State HWork Done �J <br /> r, <br /> PUMP, REPAIR: 14State Work Done �,,,��• I <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth k <br /> Describe Material and P-roce ure ' <br /> I ,hereby certify that I have prepared this application andthat the work will be done in accordance( <br /> with San Joaquin County 'Ord'inances ,, State 'Laws, _and-Rul1es and Regulations of the San Joaquin Local <br /> Health District."-Hbme owner or licensed agent's signature certifies the following: <br /> "I certify-�that i.nthe performance of the work fore wf _c.h this permit is issued, I shall ' <br /> not empZoy_ any person in- such manner as to become subject to Workman's Compensation I <br /> laws of Caiffornii " <br /> I WILL CAL DRk':A::GROU- IN E:CTION PRIOR TO GROUTING AND to FINAL INSPECTION. <br /> SIGNEDTITLE : x DATE: c:�J �/� <br /> DRAW PLOT; PL N ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY � DATE .611-1-17 <br /> ADDITIONAL COMMENTS: I N <br /> PHASE II GROUT INSPECTIO PHASE I I INAL INSPECTION <br /> INSPECTION BY DATE ' <br /> INSPECTION B <br /> EH 1426 ReV_ i -77 , <br />