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[F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I—MUFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No-2,T_-1_<--4_3 <br /> Telephone: (209) 4.66-6781 <br /> k C AV Date Issued & _ e' <br /> APPLIjCATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />► This Permit Ex ires 1 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 her..eiin 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 /> s XA T S�TREET ADDRESS CITY/TOWN <br /> l /C cam, {1 <br /> Y`cK r. <br /> Owe`s Name . Phone Z - <br /> Address -, L�m f7l4tc:` City . <br /> , . <br /> Contractor' s Name icense# Phones GG? X36 Ce <br /> e IS CERTIFICATE OF WORKMAN'S 00IMPENSATIOIN INSURA"!CE ON FILE WITH. SJLHD? YES _ NO <br /> TYPE OF WORK (Check) : NEW WELLIKI DEEPEN ❑ RECONDITION (D DESTRUCTION d <br /> WELL CHLORINATION p WELL ABANDONMENT ® OTHER 0 ' <br /> PUMP <br /> _INSTAL LAT ION JWPUMP REPAIRO RUM PIREPLACEMENT.C= <br /> DISTANCE TO NEAREST: SEPTIC' TANK 4oio SEWER LIMES -PIT PRIVY <br /> SEWAGE DISP SO AL FIELD,//&e--- CESSPOOL/SEEPAGE PIT OTHER - ci1 <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLI-C DOMESTIC WELL -= (A <br /> INTENDED USE TYPE OF WELL t1, CONSTRUCTION-"SPECIFICATIONS <br /> Industrial CableJool e Dia. of We11. Excavati-on-i <br /> C <br /> Domestic/private Drilled Dias. <br /> sof Well } � <br /> Ca_sing`___ <br /> Domestic/public Driven Gauge of Casing jO(IC- <br /> Irrigation <br /> GIrrigation I I t �-)%Cl� Gravel Pack Depth of Grout Sea <br /> Cathodic ProtectionRotary _Type of Grout <br /> Disposal Other 'Other Information <br /> Geophysical . Surface Seal Installed,b <br /> PUMP INSTALLATION: Contractor 4- <br /> Y <br /> Type df Pump_ _ ' H.P. '[%, <br /> PUMP REPLACEMENT: r] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> 6 _ <br /> DESTRUCTION OF WELL: Well Diameter Approxi ate Depth <br /> Describe Material ana Procedure <br /> l <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 G_UgT I PE'CTION OIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEQy TITLE: DATE: <br />` DR W PLOT PL N ON REVERSE SID <br /> . 1 F R P R MENT USE ONLY !'I <br /> PHASE I <br /> APPLICATION ACCEPTED BY 3 DATE <br /> ADDITIONAL COMMENTS: { - 14AR <br />' PHASE II GROUT SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION'`,BY DATE 1/J �7?__" INSPECTION BY DATE ►s'� <br />"--EH 1426 Rei_ 77° co 2M <br />