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f <br /> SAN JOAQUINA.0CAL-HEALTH DISTRICT <br /> FFICE USE: 601 E Hazelton; Avez.— Stockton, CA 95205 Permit No.Zr1&�� <br /> Telephone: ; (209) 166-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION�OR PUMP PERMIT Date Issued Z-7;9' <br /> This.. Permit;Ex fres .l':Year;From,Oate i.Iss+ ed # , <br /> CompletetIn Triplicate <br /> Application is hereby- made to the San Joaquin- .L--ocal�-Heal th,,Di strict wfor :a: perm t ,to-:construct <br /> and/or -iht'tal l the ,w6;rk herein described.,;. This,appl icatio'rn _is made::.in :compl::ian.ce with San = : <br /> Joaquin �Coun:ty,�-Ordiha.nceF No..�1862: and the. Rulves_,and' Regul atio.ns iof the. Sane Joaquin,,Local .Health <br /> District. <br /> EXACT `S>jREET 'ADDRESS ® ChTY TOWN <br /> Owner's Name /i4-/1 >� � i � [l _ Phone k7 <br /> Address --- _ r <br /> �o:fix �l��' __o. � Ca t y <br />` Contractor's Name<ih& /�C, License# Phone me a327 <br /> E IS CERTIFICATE OF WORKIZAN'S CO"iPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> ,,XELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ _ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP. REPLACEMENT ❑ Ic <br /> DISTANCE TO NEAREST: SEPTIC TANK—! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ______ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation ° .=7"r .Sw <br /> Domestic/private Drilled Dia. of Well Casing S, <br /> Domestic/public `' Driven Gauge of Casing zp _ <br /> Irrigation Gravel Pack Depth of Grout Seal SCS <br /> I� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal °Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor — <br /> Type of Pump H.P. <br /> PUMP. REPLACEMENT: []State Work Done <br />` PUMP REPAIR:. ❑State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br />' I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. dome 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." -, F <br /> I WILL CALL FOR A GROUT INSPECTI N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED s TITLE: DATE: <br /> DR W PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />! PHASE I <br /> APPLICATION ACCEPTED BY DATE 7- 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION J PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE `INSPECTION BY DATE <br /> t FH 142A RAv - 19-77........ . ._ - _w _ _ -1178, -2M, <br />