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- --------- <br /> SAN <br /> -SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. S ZS <br /> Telephone: (209) 466-6781 <br /> J APPLICATION FOR WELL-ZONSIRUCTION OR PUMP PERMIT Date issued , <br /> -('Complete In Triplicate) '- <br /> Application is hereby made to the San Joaquin Local Health. Di.sjtrict 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 Ru les and RegulAtions of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS L� , �- p` � ' CITY/TOWN cctm o ., <br /> er- <br /> Owner's' Name �'/n, �0Atrs7�c. a ,� Phone �. <br /> ` �,f <br /> Address p �. - .` <br /> Ci <br /> Contractor's Name X44P-0, 1449cense# 23 phone— '16 7 9- <br /> i IS CER7If_I.GATE--OF WORKIaAtd!-S-COQ"PENSAl IOC!-I-NSURAINCE'ON-FILE-WITFI_!�JCHD? YES } <br /> TYPE OF WORK .(Chet k) EW WELL DEEPEN O ;RECONDITION DESTRUCTION <br /> .x y _.f. "'WELL CHLORI ATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> �N PUMP INSTALLATION$4 PUMP -REPAIR LD E PUMP REPLACEMENT [� <br /> [ DISTANCE TO NEAREST: SEPTIC TANK , f f <br /> SEWER LINES .- .;S'_' IT PRIVY Ale Alk � ,C <br /> SEWAGE DISPOSAL FIELD114v- ESSP OL/S EPAGE k7_VVb-4_A-_ OTHERA1&.eve <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL P <br /> , INTEND C UBLIC DOMESTIC WELL . <br /> ED USE TYPE OF WELL t .y. <br /> Industrial CONSTRUCTION SPECIFICATION <br /> Cable Tool Dia. of Wel'1. Excavati on A„? <br /> 1 :: ^Domestic/private Drilled, <br /> ,Domestic/public Dia.�ofv. fell Casing �r <br /> Driven Gauge of Casing r'. /-4- <br /> Gravel �, p <br /> r � Irrigatl0n <br /> Pack „ Depth of Grout Sea •k. <br /> ;Cathodic Pr,otecti.on Rota-r <br /> y� Type -Grout <br /> Disposal Other A <br /> ; , Geophysical Other Information <br /> PUMP P INSTALLATION: Contractor f Surface Seal Insta ed b <br /> Type of Pump �L rt L�-1 e,- <br /> H.P. <br /> PUMP REPLACEMENT: <br /> M]State Work Done <br /> PUM <br /> P REPAIR: <br /> ❑State, Work Done_ <br /> DESTRUCTION OF WELL: Well DiameterY <br /> ' Describe Material and Proce ure Approximate Depth' i <br /> I hereby certify that I have prepared this application and that the work will be done in ac <br /> with San Joaquin County Ordinances , State Laws, .and Rules and Regulations of the done in ainQLdlanc <br /> Health-District. Home owner or licensed agent's signature certifies the followin <br /> "I certify that in the performance of the work for which this permit is issued, ; shall <br /> ;,not employ any person in such manner as to become subject to Workman's Compensation <br /> ;caws ;of Cal ifornia." m <br /> I WI.LL CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A'FINAL INSPECTION. ' <br /> SIGNED , <br /> TITLE: — �Z�v-�-�� DATE: /b3 --79 <br /> D P N ON REVERSE SIDE <br /> PHASE I- FOR DE ARTMEN USE ONLY <br /> r <br /> APP—LICATION ACCEPTED BY T <br /> ADDITIONAL COMMENTS: DATE / Z <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHASE III FINAL INSPECTION` <br /> DATE INSPECTION B <br />=H 14 26 Rev. 9/78 DAT - <br /> 3' ii �7.o n~r, <br />