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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. "7q- 600 <br /> Telephone,.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedAIIIZZJ <br /> This Permit Expires 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 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. �71,4,M/ CFnS7-'0P D,4t/<S P.D- <br /> �? 1030 OcIv;.5 <br /> EXACT STREET ADDRESS IM/ S o /�' BELT/E� 7� CITY/TOWN C0,91 <br /> Owner's Name X496 Phone 376Y--I(a <br /> Address . �5~ S �,�E=5 Biu T �9-iCE City lD4/ C09— Q' <br /> Contractor's Name <br /> 16111 77 �,xz License# 3370ffZ Phone 7 33'77 J`4 <br /> IS CERTI-FICA-T-E�OF 140P,.K�-lArl-'-S—CO�'.P.ENS; <br /> TYPE- OF.-WORK (Check) : NEW WELLS DEEPEN RECONDITION ❑ DESTRUCTUNE3, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP ,REPLAC.EMENT-Q � <br /> DISTANCE TO NEAREST: SEPTIC TANK ----�£W£R LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT R r <br /> PROPERTY LINE/-G-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -----y" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation- 12 <br /> Domestic/private __ Drilled Dia. of Well Casing1,23 <br /> Domestic/public Driven Gauge of Casing/ / <br /> Irrigation Gravel Pack Depth of Grout Seal --� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal other other Information -- <br /> Geophysical Surface Seal Installed b -: w; I <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump <br /> PUMP REPLACEMENT: , {E]State Work, Done _ <br /> PUMP REPAIR— 1-'QState W.ork,; Done <br /> DESTRUCTION�OF-'WLL: Well Diameter Approximate`Depth <br /> --Describe Maters a van Proce ure <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. Home owner or,'Jicensed agent' s signature certifies the following: <br /> "I certify that in the perfor ahce; of the work for which this permit is issued, I shall <br /> not employ any person in such .r6anner `as to' become subject to Workman's Compensation <br /> laws of California." / <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPE TION. " <br /> SIGNED TITLE: DATE: &Z—7 <br /> (DRAW PLT PLAN ON REVERSE SIDE <br /> F.OR DEPARTMENT USE ONLY <br /> PHASE 1' % // <br /> APPLICATION ACCEPTED BY DATE b <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE7 ' <br /> INSPECTION BY 0 � �3 ,. DATE �'-�l- l� <br /> EH 1426 -Rev- 12-77_ _ . -1.178 7M <br />