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f SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR FF-TCt USE: 1 1601 E. Hazelton Ave. , Stockton, ' CA 95205 Permit No.0- ' s' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WEL-L °CQONSTRUCTION OR PUMP PERMIT Date Issued' - -•�9 <br /> This Permit Ex p i res 1 Year FI^om Date " Iss'ued <br /> Complete 'In Triplicate <br /> f <br /> Application is hereby made to the San Joaquin Local. Health District for a perm o construct <br /> and/or install, the work herein described: This.'.appli,cation 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. <br /> EXACT STREET- ADDRESS 333/ CITY/TOWN Lllc <br /> Owner's Name Phone - - <br /> 7- P <br /> Address Q 133 - 3 City_.LDG, .� <br /> Contractor' s Name ' -71 3 - . �, '!CGlr Li cense#337a$,?--Pbone-- 3 77 <br /> IS CERTIFICATE OF WORKMAN'S C01MPENSATION INSURANCE ON FILE 1� ITH. SJLHD? YES <br /> TYPE_ OF 4�ORfC_(Check) :. NEW WELLS DEEPEN Cl ".,.RECONDITTO.N: . .� C ON[] w <br /> _� WELL CHLORINATION Q WELT-'«'h8MDWENT 0 OTHER 0 <br /> PUMP I NSSTTA�LLATJ&t --'p'UMP REPAIR-0 PUMP REPLACEMENT [� . <br /> ► DISTANCE TO NEXk1=5 '�"""-SEPTICjANK SEXIER EINES PIT PRIVY � <br /> SEWAGE'DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER ' <br /> ' y '`L�INEz-. A <br /> � . PROPERTYPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IAIVTENDD USE TYPE,:OF WELL CONSTRUCTION SPECIFICATIONS <br /> hdust ial Cab'le Tool Dia. of Well Excavation—/g2-'/4t--ZS7 G <br /> Domestl-c/private Oril,led Dia. of Well Casing <br /> Domestic/pu�]i,c $ Driven Gauge of Casing <br /> I r r i g i obi — l <br /> .-* ------ Gravel Pack Depth of Grout Seal _..,....,_. £ <br /> Cathodilc Protection 'Rotary* Type of Go t <br /> Disposal Other Other In on �- <br /> Geophj s[icaI Surface l wlnstal.jzd by <br />} PUMP INSTALLA ION: Contractor <br /> r 4 Type of Pump` , H.P. <br /> PUMP REPLACEMENT: E] State Work Done <br /> PUMP� REPAIR: Q State Work Ddne <br /> DESTRUCTION. OF WELL: Well Diameter ,Z'Approximate Depth <br /> Describe MateriaI a o e ure <br /> — -- <br /> .. . <br /> I hereby certi� y ha e -prepared'th pplicatio that e w rk wil be done in accordant( <br /> with San Joaquin County Ordinances , at ws , u s and R u}at ns o the San Joaquin Local <br /> Health District. Home owner or licensed gent' si ture cert es a ollowing: <br />} "I certify that in the performance, of the wo k or which his per t is, issued, I shall <br /> not employ any person in such manner as to ome sub ' c o man's Compensation <br /> laws of California'." <br /> I WILL CALL FOR A GR UT INSPECTION PRIOR TO GROUTING AN A INSP CTION. Rye <br /> r SIGNED ATE:-�- -�� �� <br /> (DRAWPLOT PLM ON REVERS S O E / <br /> FOR DEP RTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEY- 3'�- 29'- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: `w 2. ;4%1. <br /> PHASE II GROUT INSPECTION PHASE II-I FINAL INSPECTION <br /> INSPECTION BY DATE I SPECTION BY -DATE <br /> 6�1426 Rev. 12-77 /78 2M <br />