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, SAS' JOAQUIN.•L•OCA4 HEALTH DISTRICT <br /> FOR FFICE USE: 1601 l iazelton Ave.,; Stockton, CA )5 Permit No. 7,9—lly <br /> Telephone:; (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9-�9 <br /> This .Permit Expires 1 .Year From .Date Issued <br /> f Complete . In Trip icate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install tiie+work herein described. ,This application is made in compliance with San <br /> ;oanuin County,Ordinance' �:o: 1862 and the ules and Regulations of the San Joaquin Local Health <br /> Gistr�ct. ' <br /> EXACT STREET ADDRESS. 4- -7r 2 1 \\ CITY/TOWN7� Z c�( <br /> Owner's Name S Phone Vi'D-i <br /> Address -W .. City.'�YQ.� <br /> Contractor' s Name ,z \A,r L License#/x,-m Phone SZ 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHO? YES ✓ NO <br /> TYPE OF WORK (Check) : NEW WELL0_ DEEPEN O RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION O WELL ABANDONMENT 0 OTHER O <br /> PUMP INSTALLATION O� PUMP REPAIR O PUMP REPLACEMENT O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIS 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 Drilled Dia. of Well Casing <br /> Domestic/public driven Gauge of Casing S� RC1 1 1 _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �'_ o w <br /> Disposal Other Other Information <br /> Geophysical \Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractory, r.-� <br /> Type of Pump_ �A H.P. 1 1AV., <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 Locale <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 UOUT INSPECTION. PRIOR .TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED DATE: J` <br /> JORAW PLOT- PLAN ON RLTERSE SIDE <br /> FOR'DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLI AT ION ACCEPTED BY / �_ e�ti, iJ� �•� DATE �— 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATES�j�' <br /> cl (� <br /> N <br />