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SAN JOAQUIN LOCAL HE;ALI H UIS E KIL <br /> Stockton, CA 95205 Permit No.zq,/„�-S <br /> FFICE USE: 1601 E. Hazelton .Ave. , <br /> Telephone: ''(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g', <br /> This Permit Expires 1 Year From bate Issued t <br /> Cbmplete 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 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. <br /> EXACT STREET ADDRESS 11Zc3 VJQa i C1,0LAIL CITY/TOWN <br /> Owner's Name t4r-'LIX Zl A (! S Phone <br /> Address C Laic Ci,tyE 3F- <br /> F License#-7 __ .- Z--� <br /> Contractor s Name Phone <br /> - <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATIOIN INSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELDEEPEN [] RECONDITION ❑ DESTRUCTION: <br /> WELL CHLORINATION C1 ;DELL ABANDONMENT 0 OTHER 0 _ <br /> PUMP INSTALLATION-?Op PUMP REPAIR❑ PUMP REPLACEMENT 13 <br /> DISTANCE TO NEAREST: SEPTIC TANK /jgn, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL7FIELD CESSP OL/SEEP !E PIT OTHER r <br /> PROPERTY LINE -. PRIVATE DM ESTIC WELL� PUBLIC�O STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS` <br /> ndustrial Cable Tool ., Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing Ci <br /> Domestic/public Driven i Gauge of Casing / 2 <br /> Irrigation Gravel Pack 'Depth,of GroinSeal a <br /> Cathodic Protection =Rotary t '`� ' Type bf Grout <br /> Disposal Other Other Informati( <br /> Geophysical yS.urfa.ce_S.eal._I.n.stal 1 ed b <br /> PUMP INSTALLATION: Contrac-tor ` <br /> Type of Pump <br /> PUMP REPLACEMENT: — t �M-State4Work. Done ' + <br /> PUMP REPAIR: Q StateiWork one <br /> ---�= _. _ _ A rox�mate De 4th <br /> DESTRUCTION OF--WELL=: Well 4 D i ameter }� ` `� p�it� _. _ <br /> Describe Materia and �Proce ure t t <br /> E + <br /> I hereby certify that I have .prepared this application and that the work Wille done in accordance <br /> with San Joaquin County Or State Laws , and Rules'�and Regulations Wthe San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> ".I certify that in thepp formance of the work for which this-permit Lis issued, I shall <br /> not employ any .person in such manner as to become subject to Wdrkman's Compensation <br /> laws of California. " `" <br /> I WILL CALL FOR A GR UT IN PECTION PRIOR TO GROUTING AND,A"-FINW-INSPECTs1001. <br /> i <br /> SIGNED TITLE:. r; ,.= DATE: <br /> -- A — L N ON REVERSE'SIDE <br /> DR W PLOT <br /> -F R`-'DEPARTMENT-'USE -ONLY-,--c — <br /> PHASE I 1 C. <br /> APPLICATION ACCEPTED B DATE <br /> ADD I TTONAL COMMENTS_:—,- _..-- -.,_. ..., <br /> PHASE II GROUT INSPECTION, PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-7� <br /> Fir I a9r, oo„ 19-77 w 1/78 .2M_ <br />