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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 3-3 <br /> Telephone: (209) 466-6781 <br /> r. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 A nstall 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 CITY/TQWN SZyc"/C 7.oni <br /> 6.�wner's Name V, L g L__ 4 &P- r Phone / .S - ei A <br /> Address �.aw,� City." 9X� 2 s <br /> ,,;ontractor's Name rDxJn�s�,� 1A� / Licensetfg2 /zf/zf Phone 0/ � lrr;/ _,__• <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"ICE N FILE WITH SJLHD? YES -,Y NO <br /> .TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Z RECONDITION DESTRUCTIONF1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION L7 PUMP REPAIR❑ PUMP REPLACEMENTIE] <br /> DISTANCE TO NEAREST: SEPTIC TANKSD 14 SEWER LINES,<2y �f"_PIT PRIVY <br /> SEWAGE DISPOSAL! FIELD�Q4 CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LINE/6 4PRIVATE DOMESTIC WELLS2- 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 T <br /> Irrigation Gravel Pack Depth of Grout Sea ya / <br /> Cathodic Protection Rotary Type of Grout <br /> ` Disposal Other Other Information <br /> - Geophysical Surface Seal Installed by: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: ❑State Work Done <br /> `PUMP REPAIR: ❑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 accordar <br /> %.vith San Joaquin County Ordinances, State Laws , and Rules and Regulations- of the- San Joaquin Lou <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 /> 1 WILL CA FOR . GRP T I SP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> �iIGNED ' TITLE: oulv ZDATE: ? Fi< <br /> DRAW PLOT PLAN ON REVOR-STJ11DE2 <br /> �'HASE I FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY DATE /9 7� <br /> IDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI <br /> INSPECTION BY N DATE INSPECTION BY \.M DATE \ 119 <br />