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S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton 'Ave. ,Stockton, CA 95205 Permit No.�?9_ � 2Z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 4 - <br /> '(,Complete <br /> -'(Complete in' tripl'icate) Nee C•OAIPS-'7'-. <br /> Application is hereby made to the San Joaquin Local Health District fora 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. ® ,� 4Q )V k49-rKl/JS: a CITY/TOWN�f�Gt ^ <br />'Owner's Name MN . A) /9�Z 1 C Phone 2-3 •-x23477 <br /> Address X23 l- ty City <br /> Contractor's Name , 'i/ '° I-L R L-0&1 License# ,?/;3 Phone 36F- 477 <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATIOM INSURANCE ON FILE WITH SJLHD? YES- - 0 <br /> TYPE OF'WORK (Check) : NEW WELD DEEPEN 0 RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHERF-1 N <br /> PUMP INSTALLATION` R� PUMP REPAIR 0 PUMP REPLACEMENT [] <br />.DISTANCE TO NEAREST: SEPTIC TANK 0A/K SEWER L NEIVOAle- PIT PRIVY � <br /> OC N <br /> SEWAGE DISP SAL FIELD/JvWr- CESSP OL/S EP A GE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLIPUBLIC DOMESTIC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4-1 <br /> Industrial Cable Tool Dia. of We7l Excavation <br /> _Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing :X 4- <br /> Irrigation Gravel Pack Depth of Grout Sea L7- <br /> Cathodic Protection Rotary Type of Grout Cc M q=luT —A <br /> Disposal,. -s Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor_ to V IC L,L aj L I N C. p pti Sg1z✓1.0 <br /> ryPe, q-Jump- mo::. H. S4 �P• <br /> PUMP REPLACEMENT: C]StateWork Done ' I <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 r <br />.1 hereby certify that�I _ha.ve prep"' this application and that the work will be done in accordance <br /> wilth 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 CA L FOR A GROUT SPECTION 'PRIOR .TO .GROUTING_AND, A'FINAL, INSPECTION. <br /> SIGNED _ TITLE: '`� DATE: to — <br /> D PL ON REVERSE SIDE <br /> F <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> PP�' LICATION ACCEPTED B . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY : DATE_7-s 7lf INSPECTION BY_fi &7 DATE ,,2y, Z j <br /> EH 14 26 Rev. 9178 . . /7Q 1) n <br />