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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _FOR-E ICE E: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - 7� <br /> _ p 4 7/� <br /> Telephone: (309) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex ires I 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 /> ,'oaouin County Crdinance No. 1862 .and the Rules and Regulations of the San Joaquin Local Health! <br /> D i 5 t r j c" . Zoo—0 1 <br /> o75 <br /> EXACT STREET ADDRESS <br /> CITY/TOWNx� H ' <br />-Owner's Name AlVe �ar•n�c•� ��� G'/"rosa��r� Gc� Phone <br /> City4Rg'. <br /> Address . �, a Z* J <br /> Contractor's Name—,,X.& e �v r' License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI011 INSURA?SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :-7 NEW WELD DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER F <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <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 /> Domestic/private v�'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 /> a Qud//�y ,GP19//arid "/ rface Seal Instal led b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: []State Work Done ,x <br /> PUMP REPAIR: QState 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 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 SSR OR ROUT ION,�,�� <br /> SIGNED TITLE: �6j1S XATE: <br /> ted. r W <br /> PLOT P N ON REVERSE SIDE <br /> FOR DEFARTMENT US <br /> PHASE I r <br /> APPLICATION ACCEPTED Y t/ DRTE .�✓ a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE R-�' <br /> EH 1426 Rev- 1277 _ _ (✓�!/s ���•�'��/�.�*� c�-e e.,.��t• � 7 8 • <br />