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MFFIr;: SAN JOAQUIN LOCAL HEALTH DISTRICT USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.J,;,-5-)(, <br /> Telephone: (299). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -5-7 <br /> (,Complete In Triplicate) <br /> A <br /> Appl . tion'is 'hereby made to the San Joaquin Local Health District for a `p`ermitto cnstruct <br /> and/or install the work herein described. This application is made in complianc6- Wit.h San <br /> Joaquin County Ordinance No. 1862 and. the Rules and Regulations of, the .San Joaquin local Health <br /> District. , <br /> - EXACT STREET ADDRESS 767 S `'' CITY/TOWNG <br /> Owner's Name C f Phone S- f F-2,5 Z� <br /> Address 5 Cy ty. .. <br /> Contractor's Name License# Phone Z_ <br /> Z_: <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAMCE 'ON FILE' WIT1I-SJLHD? YES go } <br /> TYPE OF WORK (Check) : NEW WELL 0 - DEEPEN ❑ RECONDITION DESTRUCTION[], <br /> - -� . WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER F-J n �; <br /> ' PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT C! ' <br /> .J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Y <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .. . <br /> PROPERTY LINE_ -,. PRIVATE DO ESTIC WELLPUBLIC DOMESTIC WELL . <br /> .- INTENDED USE TYPE _OE WELLz- , (�ONSTRUCTION SPECIFICATIONS <br /> _Industrial Cable Tool's - Dia: of Well Excavation <br /> _Domestic/private DYI11ed ., Dia: of Well Casing <br /> - omestic/public Driven �'� Gauge of Casing ! <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary .' , Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical <br /> �, ,,.Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor r -' _ ° <br /> r x � <br /> ,. iv Type <br /> PUMP`.REPLACEMENT: ]State Work Done <br /> PUMP' REPAIR: QState Work Done _ 4--A <br /> DESTRUCTION OF WELL: Well Diameter � g Approximate Depth <br /> Describe Mater15and Procedure i <br /> I hereby -certify that I have <br /> .. 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 -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 OR A GROUT PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED k <br /> - &,.clTITLE: -�, DATE:_, f 7;e <br /> DR PLT <br /> PLAN ON REVERS SIDE <br /> °: FOR DEPARTMENT USE ONLY <br /> PHASE I = � ..�. <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION T PHASE II FINAL INSPECTION <br />�NSPECTIONBY DATE INSPECTION BY DATE 6- zc/'-7 <br />.H 14 2b' Rev. 9/78 9/7$ ZM <br />