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eg' /& e SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR 0FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 952.05 Permit No. J�--5 70 <br /> Telephone: (209) 4.66-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (,Complete In Triplicate). <br /> Application is hereby made to the San Joaquin Local Health .Distric-t' for-a permit to construct <br /> and/or .instal:] 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. rr <br /> EXACT STREET ADDRESS 0�.� Id�p l'�` CITY/TOWN <br /> E Owne'r's Name1 � ,r� `�,-g ,/� 'C) Phone <br /> F Address o ,3 _ ' City ' <br /> Contractoris Name License# /f,4F7, fhone <br /> .IS CERTIFICATE OF WORKMAN'S COMI TION INSURANCE ON FILE WITH SJLHD? YES 0 � <br /> TYPE-OF WORK (Check) : NEW WELL 0 DEEPEN 0, —RECONDITION [D DESTRUCTION[n _ �J <br />' WELL CHLORINATION 0 7WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP. INSTALLATION , PUMP REPAIR 0 -PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. .,. _ ' ., PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD_`: -- CESSPTO_L/SEEPAGE PIT OTHER . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE. OF WELLu CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We l 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 /> a Cathodic Protection , Rotary Type of Grout 4 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br />► PUMP .INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: Q State Work Done _ G <br /> PUMP ( State Work Done / a <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate Depth -- <br /> Describe Material and Procedure = w <br /> I hereby certify that I have prepared this application and that the work will be done in accordant( <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 certifythat 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 Califbrnia. <br /> I WILL CALL)FOR A GROUT INSP T P IOR--M GROUTING AND A-FINAL INSPECTION. <br /> " SIGNED � - LE: o DATE: <br /> ' L L ON REVERSE SIDE �� <br /> OR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INS Q <br /> PECTION BY DATE INSPECTION `BY__ _[���� DATE 2• <br /> k,EH 14 26 Re,v._ 9/7.8 p- 9118 '' ' 2M <br />