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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FFI.CE USE: 160I E.- Hazelton Ave. ; Stockton, CA 95205 Permit No_ - <br /> ---�� — Telephone; (209) 466-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This .Permit Ex ires .l. Year Fro6 Date Issued. <br /> Complete In Triplicate <br /> - , <br /> Z�Z2��. Ido✓� <br />( Application is hereby made to the San Joaquin Local Health District for a permit -to construct <br /> and/or install thelwork herein described. . This ,appliCation is made in compliance with San <br /> ,oanuin County Ordinance- No. 1862 -and the Rules and Regulations of the San Joaquin Local Health <br /> ''istrict. <br /> EXACT STREET ADDRESS. 6 2CITY/TOWNOwner's Namec•�.N d- 4a= Phone „67f _ .— <br />' Address � � - .� �',, - _ _ .. City <br /> Contractor's Name h. G License# Phone <br /> IS CERTIFICATE OF­.WORKMANIS CQMP-ENSAT.ID'4� .-I.t1SU.RAIICE."Orl' FILE -WI-TH SJLHD? - -YES NO <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN ❑ RECONDITION ❑ DESTRUCT.IONIU <br /> WU L CHLORINATION.a . WELL ABANDONMENT ❑ OTHER ❑ l <br /> PUMP INSTALLATION PUMP REPAIR Q PUMP REPLACEMENT <br /> .. 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER—LINES PIT PRIVY <br /> � . SEWAGE DISPOSAL FIELD -, CESSPOOL/SEEPAGE PIT OTHER • <br /> 0` <br /> -PROPERTY LINE -, PRIVATE -DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF�WELL CONSTRUCTION SPECIFICATIONS <br /> .� N <br />_ Industrial .. ';�' Cable Tool Dia. of Well Excavation <br /> Domestic/private � Drilled Dia. of Well Casing <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 Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> P ❑State Work Done <br /> ESTRUCTION.OF WELL <br /> � Well Diameter P,,,u,,,11 <br /> L��� Approxim4te ep�thDescribe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Nith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local i, <br /> lealth 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 /> laws of California. ” <br /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> ' <br />[ WILL CALL FOR A G INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />:IGNE: - TITLE: DATE:-7,19-IS <br /> DRAW PLOT PL N ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY <br />,PPLICATION ACCEPTED B W�A <br /> DATE <br /> ADDITIONAL COMMENTS: — - — <br /> PHASE II GROUT INSPECTION PHASE•-III FINAL INSPECTION <br /> NSPECTION BY DATE �- INSPECTION BY Gv I DATE �f / 7,�F = <br /> H 1426 Rev. 12-77' . <br />