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CGM /a y/eGf SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR OFFICE USE: 16(,,�_. Hazelton Ave. , Stockton, CA 5205 Permit No.Z 76y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S '� <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 / Q / 7 E k1 CITY/TOWN <br /> Owner's Name [r2o r. An r. a Phone <br /> Address "T �¢c.Xraa.. Ail 6, City . <br /> Contractor's Name r ' License#/y.3 —/7S�Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPE TI '! INSURANCE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WORK (Check) : NEW WELL q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATIOiN ❑ WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT 0 -t <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> cX omestic/private Drilled Dia. of Well Casing c <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> S a&iu . <br /> Type of Pump f .SA�.r ✓ . H.P. / -✓" <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: [OState 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 accordant <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca' <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 INSPECTION P IOR O GROUTING AND A FINAL INSPECTION. <br /> SIGNED k ITLE: e DATE: <br /> W L T PL ON REVERSE SID <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I �n <br /> APPLICATION ACCEPTED BY l,� �` DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' DATE - <br /> ru 1AIC o.... +n 77 1 /751 W <br />