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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR-OFFICE USE 1601 E. liazelton Ave. , Stockton, CA 95205 Permit No. 7sr_�j6,t9J <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/4-/Z:2 <br /> (Complete In Triplicate) k <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 /> 4V <br /> ,,3 —^, ,mayb CITY/TOWN .S <br /> EXACT STREET ADDRESS _ <br /> Owner's NameAIX <br /> i - Phoney/r= 33 - <br /> Address 6f7-V <br /> Contractor's Name u f t ,0,_,A_k1-AJe- License#?V`4Jz,3 Phone 368- 1(.-7,6 :x <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATIOM , INSURANCE ON FILE WITH 'SJLHO? YES NO <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN 0 RECONDITION Q DESTRUCTION S � <br /> WELL CHLORINATION Q WELL ABANDONMENT <br /> ,0- OTHER 0 <br /> PUMP INSTALLATION 9� PUMP REPAIR 0 PUMP REPLACEMENT [J <br /> DISTANCE TO NEAREST: SEPTIC TANK /571-' SEWER LINES ` PIT PRIVY ry_ . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLY DOMESTIC WELL - <br /> INTENDED <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial--- _Cable Tool Dia. of Well Excavation ,r _ <br /> Domestic/private Drilled Dia, of Well Casing E2. 11 - ' <br /> Domestic/public Driven Gauge of Casing . '9 <br /> Irrigation Gravel Pack Depth of Grout Seams <br /> Cathodic Protection Rotary Type of Grout Me- <br /> Disposal Other Other Information - ' <br /> Geophysical Surface Seal Insta _ ed-by:_ <br /> PUMP INSTALLATION: Contractor sex,� L / � <br /> Type of Pump ,� ? <br /> . ' . <br /> FPUMP REPLACEMENT: Q State Work Done <br /> i <br /> PUMP REPAIR: Q State Work Done •�� �w <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 acc rdance <br /> with San Joaquin County Ordinances , State taws, and..Rules and Regulations of the San Joaquin- Local <br /> Health District. Homeowner or licensed age-nt' 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 WILLACAFOR A GRO NSPECTION PRIOR TO GROUTING AND A' FINAL 'INSPECTION. ' <br /> SIGNED ;K� <br /> TITLE: �-- DAT E:/d /,r <br /> W PL ON REVERSE IDE <br /> OR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL <br /> INSPECTION BY . _ DATE Zj Lzy_-9$`" INSPECTION BY _ DATE I��•. <br /> EH 14 26 Rev. 9179 <br />