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FFICE USE: SAN JOAQUIN LOCAL HEALTH` DISTRICT <br /> 1601 E.._ Hazelton ,Ave. - .Stockton, CA 95205 Permit No. <br /> -- Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �f.s�Zg% <br /> ` This Permit Ex i.res 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made- to the San Joaquin Local Health District for a ermi <br /> and/or install the work herein described. P . - t to construct <br /> and/or install <br /> Count This application is made in compl.iance with San <br /> -y :Ordinance �o. 3862 and the Rules and Regulations of the San Joaquin ,:Local Health <br /> UiStr?C�. <br /> f EXACT STREET ADDRESS <br /> CITY/TOWN /J'. <br /> Owner' s Name <br /> 1 Address S , c`�� % Phone <br /> �.. .� Cit <br /> Contractor' s Name y <br /> IS CERWORKMAN <br /> li -L LLlense#. i Phone . �- / <br /> TIFiCATE OF WORKMANIS CO'HP64SATIO"1 I�iSURA"10E OPl FILE WITH SJLHD7 <br /> YES NO <br /> I TYPE OF WORK (Check) : . NEW WELLM- DEEPEN ❑ RECONDITIONDESTR <br /> WELL CHLORINATION ❑ WELL ABANDONMENTN <br /> ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ 4� <br /> DISTANCE TO NEAREST: SEPTIC TANK / D <br /> SEWER LINES/�"nf PIT PRIVY <br />! SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL S� ' OTHER r� <br /> INTENDED USE PUBLiC DOMESTIC WELL <br /> ��Industr Dal TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Domestic/private =� Cab-1e Tool Dia t of WeII Excavation <br /> I—AVEDomestic/public !- - Dia, ;ofe Wellz Casing le <br /> rrigationDri.ven Gauge of Casing <br /> Gravel Pack` Depth of Grout Seal Q <br /> Cathodic Protection Rotary ,. ^ 4 ' - <br /> Disposal 0Otary Type of Grout ` •-- � <br />----___Geophysical Other <br /> Other Inf <br /> ormaton .., <br /> , <br /> -_.—Surface- Seal.` I-nsta'1 :ed b <br /> PUMP INSTALLATION: Contractor ^ T... f� <br /> Type of:': bump s <br /> PUMP REPLACEMENT: ' " <br /> `` • M.P. , # <br /> 7 Q State •Work ;Done.; r f <br /> PUMP REPAIR: <br /> ❑State;Work Done <br /> DESTRUCTION OF WELL: Well Dia' <br /> meter <br /> -teri <br /> ,,)Approximate Depth ^� <br /> Describe-'M6 a `an �"Proce.dur .. _ A <br /> I hereby certify that I have prepared this application and that the <br /> in <br /> vith San Joaquin County Ordinances , State Laws, and Rules and Regulationswoflthe Joaquinaccordan <br /> iealth 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 /> WILL CA L FOR A GROu INSPECTIOfV P_R.I_0.R_.TO GROUTING _ANl7__A_FINALI.NSPECTION.. _ <br /> i <br /> TITLEDATE: <br /> DR W PLOT L N ON REVERS SIDE <br /> RASE I FOR DEP TMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> 7DITIONAL COMMENTS: DATE TE <br /> PHASE II GROUT I SPECTION ' a <br /> ISPECTION BY DATE PHAS II FINAL INSPE T ON <br /> h �� INSPECTION BY DATE 3--)4, -7 <br /> _:v°: 12-77. <br />