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SAN JOAQUIN, LOCAL HEALTH DISTRICT <br /> C952O5 Permit No. - 9 b- <br />_FOR_OFF.ICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> CA Telephone: (209) 466-6781 ' <br /> "_- . y Date Issued- -? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This, Permit Expires 1 Year From Date Issued t <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 V�1 <br /> loanuin County Ordinance Ido. 1862 and the Rules and Regulations of the .San Joaquin Local Health <br /> District. <br /> CITY/TOWN�' ' E <br /> STREET ADDRESS � <br /> --4ExA T <br /> Owner' s Name O /S Phone -7S" -- <br /> Address O BB 3 City Gl �l�`NT-g 71 <br /> Contractor' s Name <br /> _5 OW IAZf! GGl�tIG License# Phoneme - 33 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO.I INSURA"!CE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) :° -.NEW WELD DEEPEN ❑ RECONDITION ❑ DESTRUCTION d`- <br /> t <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMA-'INSTALLATION �T� ..P.UMPt.REP,AIRQ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK 15e_ SEWER LINES-7577-PIT PR" VY-�_— <br /> SEWAGE DISPOSAL FIELD .;— OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ��Cable Tool Dia. of Well Excavation <br /> _Domestic/'private Drilled Dia. of Well Casing S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Sa <br /> Cathodic Protection Rotary Type of Grout C�w1 <br />� i <br /> Di'sposa�l� Other Other information <br /> Geophys_i.cal ; ' Surface Seal Installed b <br /> I�PUMP I NSTALLATJ ON: ' ContractorS'101V jS-Z_C_ ► <br /> iz Type of Pump G� H•; ----� <br />: PUMP REPLACEMENT*.,,- p State Work. Done ` <br /> PUMP REPAIR:' `(�State Work Done : E <br /> `:'� '� _ �• A Qepth <br /> DESTRUCTION OF WELL: Well Diameter Approximate ____�-;,,, • <br /> = = Describe,Materia and- 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- O.r.dinances , State Laws , and Rules and Regulations of the San Joaqdi-n -Locals- <br /> Health District. Home owne';r or licensed agent' s-'signature certifies the following: <br /> "I certify that �i-n 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 Wprkman' s Compensation <br /> laws of California." ' <br /> I WILL CALL FOR A GROUT INSPECTI N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> " TITLE: DATE: <br /> SIGNED (DRAW PLOT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY -t'xJ1 -_ _ DATE �6 .a rf 7��' INSPECTION BY DAT <br /> / . ] <br /> ru z nuc .. . o^u. 19-7 7 _ - - - - - /78' 2M <br />