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VFORSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PFICE�USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Na. 9-24z <br /> r= Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _.P_ <br /> This Permit. E'x- ires-1 Year From Date Issued <br /> Complete In Trip icate <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 Regulatiops of the San. Joaquin Local, Health <br /> District. ,ae17hc,11X;- PE/r-1,,. ' Xe: <br /> EXACT STREET ADDRESS S �O' Q A S '� CITY/TOWN Z-0,0( <br /> Owner's Name Phone 3 69 9 S <br /> Address l A4 <br /> City PI . <br /> Contractor's Name Det/ J AL License#33 p ;-Phone -75 -3 37 <br /> IS CERTIFICATE OF WORKtIAN'S COIMPENSATIO"a INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE-OF­WORK'-(-Check)": 'NEW-'WELL LI -DEEPEN;9- 'RECONDITIOWM— DESTRUCTION <br /> --WELL CHL'ORTNA7ION7E3- '`WELL ABANDONMENT 0—OTHER 0 <br /> �- --- —PUMP41-NSTALL'ATION M—PUMP `REPAIR-[3—"-PUMP-REPLACEMENT-EI , <br /> DISTANCE TO NEAREST: SEPTIC TANK &00 SEWER LINES f 6le PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - -C£SSPOOL/SEEPAGE PIT OTHER_. <br /> PROPERTY LINE RIVATE DOMESTIC WELL 4a PUBLIC DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECiFI`CATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation 2 P — ' <br /> Domestic/private Drilled Dia. of Well Casing 1=1e <br /> Domestic/public Driven Gauge of Casing La_ <br /> Irrigation Gravel Pack Depth of Grout Seal �---- <br /> Cathodic Protection Rotary Type of Grout := <br /> + 1�i,sposal Other Other Information ------ <br /> t vGeophysical. Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H7 <br /> PUMP REPLACEMENT: State Work Done ` <br /> PUMP REPAIR: Ottate Work Done <br /> ;_DESTRUCTION�OF WELLC-"Awell Diameter - =_,App�r-oxaanate--Depthl� - - <br /> Describe Material and P oceTure ` <br /> I hereby Fcertify that I' •h-ay.e,prepared this application and that the work will. be done in accordam <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca' <br /> Health Drisirict. Home owner or,/licensed agent' s signature certifies the following: <br /> "I �certifky that in the performance of the work for which this permit is issued., I shall <br /> notiemploy,any person in such manner as to become subject to Workman 's Compensation A <br /> �laws-,of California." <br /> I WILL`-..CALL FOR A GROUT, INSPECTION PRIOR-T-0 -GROUTING,-AND A`FINAL IN_SPECTION. . L <br /> SIGNED _ �T I T L E-: - - -- ._-r.DAT E: 1 ali, : <br /> (DRAW PLU-1 - - N ON -REVS SE,SIDE ! <br /> PHASE I <br /> FOR DEPARTMENT ONLY <br /> � <br /> r�- � � . Z" '` <br /> APPLICATION ACCEPTED BY DATE " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1426- ' Rav- 12=77 1/78 2M <br />