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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g_Igg,6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g-gs-,;Y8" <br /> This Permit Expires 1 Year From Date Issued 1 <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> pp y q permit to construct � <br /> and/or install the work herein described. This application is made in compliance with San <br /> -'oan�:Tn County Ordinance ".o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> r,i str�ct <br /> EXACT STREET ADDRESS_ ,Z47Z, Z2 4C CITY/TOWN <br /> Owner' s Name Phone 41 t � <br /> Address c City <br /> Contractor's Name LicenseaY9 F -q Pho'ne�, <br /> IS`CERTIFICATE.' OF WORKMAN'S COMPENSATIO"J, INSURANCE ON FILE WITH SJLHD? YES '40 <br /> TYPE OF WORK (Check) : NEW WELL Lt-- DEEPEN ❑ - RECONDITION ❑ DESTRUCTION❑ . -- <br /> WELL- CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ -s <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY c <br />'10, SEWAGE DISPOSAL FIE{LD.. CESSPOOL/SEEPAGE PIT,- OTHER 7� <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 /> testi c/private Drilled Dia' . of We-1,1-�Cas-i ng_ _ <br /> Domestic/public Driven - Gauge of: Casi ng 1A _ <br /> Irrigation -r Gravel Pack Depth of Grout `Seal �!. <br /> Cathodic Protection teary Type of Grout , <br /> Disposal Other Other Informatio d .¢ <br /> Geophysical ; Surface Seal Installed by: f- _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i,, H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Materia 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 CALL FOR A GROUT INSPECTION PRIOR T9 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT:P.L N ON REVERSE SIDE <br /> FOR D PARTME T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE BY �.� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BYE - DATE_ -r.� <br />