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,. : / SAN JOAQUIN LOCAL HEALTH UISIRILI <br /> FOR FFICE USE: 1/ 1601 E. Hazelton, Ave. , Stockton, CA 95205 Pe- mW-No. 2 �/ / 9 _ <br /> Telephone: (209) 466-6781 } <br /> Date Issued I- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit: Ex ires 1 Year From Date Issued <br /> Complete 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�0e,rein described. This application is made in compliance with San <br /> Joaquin County Ordinancg--No. 1862 and -the: Rules and ,Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET-ADDREIver CITY/TOWN Trac sr <br /> Owner's Name 14r. l" x J. Lyalos Phone none <br /> Address 11:821 -W Clover City Trac <br /> Contractor's NameClark Well & E ui ment License# 6602 Phone 462- <br /> IS CERTIFICATE OF WORKMAN'S CO"1PENSATI.0"!I�ISURAI•!CE-ON--•FILE -W-ITH-SJLHD? YES NO <br />''-f TOC 0IFWORK (Check) : NEW WELL e DEEPENPRECONDITION ❑ 'DESTRUCTION❑ _ <br /> I <br /> WELL CHLORINATION E WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION p PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO .NEAREST: SEPTIC TANK /;C)� SEWER LINES A06 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/Ve�_ CESSPOOL/SEEPAgE PIT��� OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL 6Q - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation! r� <br /> ---�7-Domesti c/pri vate r Dri 11 ed.a =, } Di`a. of Well Casing <br /> Domestic/public i Driven .-Gauge of Casing <br /> f. I rri gati ori --__-.- Gravel Pack Depth of Grout Seal �d <br /> Cathodic Protection otary Type of Grout (Q�_co o m4 GG GL <br /> Ary <br /> Disposal OtherOirhei^ Information , <br /> 3 ' <br /> Geophys`ical i Surface Seal Insta, ed, F <br /> _r <br /> PUMP. INSTALLATION: -'.- Contractor S E <br /> �. <br /> � t <br /> Type of Pump' <br /> PUMP REPLACEMENT: M<ate Work Done I_R©ilL' _ — .uM. -�pj dH- Wk# NC <br /> IN I <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF-WELL,:-Vr Well Diameter : r` -- '" = Approximate-Depth— <br /> /1!y-e2 <br /> Describe Materia a'n -Proce ure 1. <br /> aw��� <br /> i I hereby certify that I have prepared this appl ecatioon. and that!the work wi.11 be one 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 .aggn,t'_s signature gerti f i es the following: <br /> i "I certify that in the performancE'of the"workc for- which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Wprkman's Compensation <br /> 1-aws-of-.Cal for-nia:" .__. _ - <br /> I WILL CALL FORA R INS ECT •N,'PR-IOR TO GROUTING>LANVwA FINAL INSPECTION. yj� ��7 <br /> SIGNED TITLE: DATE:/!,®1/ <br /> PL N -ON`REVERSE SIDE <br /> F.W DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> AZ-7-7� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii ARPU NSP CTION PHASE III FIN L INSPECTION <br /> INSPECTION BY �'' DATE � -�--�� INSPECTION BY DATE <br /> � N I <br /> CL3 -1 A'lG 0-i `1'7-77 l/7$._77 . _ <br />