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SAN JOAQUIN .-LOCAL HEALTH OIS[RICf <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 4.66-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This PermFCo_m_p'1_ete511n <br /> .Exfre1 Year From Date .Issued <br /> Triplicate <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. n <br />} EXACT STREET ADDRESS �,UZ �ST t� W CITY%TOWN <br /> Owner's Name l 03C T �. . C LA- Phone i 2-G2 <br /> Address 0 C r C TX W) City TD C4(7DAJ <br /> Contractor's Name L ELL. ; <br /> UII PN . Cd Li cense0667- Phone 6 2-0E <br /> IS CERTIFICATE OF WORKMAN'S C01,1PENSATIO.1 'INSURANCE ON FILE' WITH SJLHD? - YES NO <br /> . TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ _DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER(, <br /> PUMP INSTALLATION ❑ �.,yUMP REPAIR❑ PUMPJREPLACEMENT ❑ O <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 Sbl SEWER LINES . PIT PRIVY <br /> SEWAGE' DISPOSALFIELD 9Z CESSPOOL/SEEPAGE PIT; OTHER <br /> i <br /> PROPERTY LINE -. PRIVAT DOMESTIC WELL '_ -RU.BLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 120 <br /> _Domesti c/private Dri 11 ed , Di-a. of 1�ei 1 Cas i rig <br /> omestic/public Driven - �„ Gauge-of Casing: , = /0 <br /> Irrigation C140avel Pack Depth of Grout Seal ___ ' <br /> Cathodic Protection ✓ Rotary Type of Grout G�EtE.IJt" <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> li PUMP INSTALLATION: Contractor 04W WELL SatUPHE 7' TNC- <br /> Type of Pump !o4 IBL N- <br /> PUMP REPLACEMENT: ❑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 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 C F R A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE: �Jl)NER DATE I 4UG . '700 <br /> (DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I el Z2 <br /> APPLICATION ACCEPTED BY DATE <br /> '. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION'. PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE__4L/90 INSPECTION BY DATE E .2 ► ��� <br /> CLI 7 AOC ❑. I9_77 .,. J _ - <br />