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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7el Telephone (209) 466-6781 <br /> P R Date Issued / <br /> PMP .. <br /> APPLICATION FOR WELL CONSTRUCTION OR U <br /> This Perm t Expires 1 Year From 'Date Isued /1`AIL_ P r(+ � <br /> Complete In Triplicate) <br /> Application-is hereby made to the Sari Joaqui_n„Local,.Health. D.istr.ict for a permit to construct <br /> and/or install the work herein described.: TFiis application ,is 'made in compliance with San <br /> Joaquin County Ordinance No i1862..and the R es nd Regulations of the San Joaquin Local Health <br /> District. - A7' <br /> EXACT STREET ADDRESS d7,-�-�/Q/f/et�i �'�� / CITY/TOWNSC� � l� <br /> Owner' s Name E // ' Phone <br /> Address City -5Le�o <br /> Contractor's Name �pe, License# _ Phone- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURA''•10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLr. DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ • <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Ei- OTHER ❑ <br /> PUMP INSTALLATION ® PUMP REPAIR❑ PUMP REPLACEMENT ❑ p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �S"EWAGE"915POSAL FIELD -CESS-POOL/SEEPAGE-1PIT OTHER- -"-`"`-"" <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �4 <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 a Driven Gauge of Casing <br /> 3 Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information-- <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 1 Reeiica,14T d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State 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 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 FORA GROUT INSPECTION PRIOR TO GROUTING AND�'A FINAL INSPECTION. / L 7 <br /> SIGNED � , , ?. TITLE: DATE. <br /> ADRAW PL T- PL N 'ON REVERSE SIDE <br /> FOR D MENT USE ONLY <br /> PHASE I ,/� ? <br /> APPLICATION ACCEPTED BY /t DATE J <br /> "ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION PHASE 116 F NAL I PECTION <br /> ,'INSPECTION BY DATE INSPECTION BY DATE _ d� <br /> FH 142.F ':Ram 77_77 —_- <br />