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0 SAN JOAQUINJLOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No-29:-)q,, <br /> Telephone: (209) 466-6781 ` '/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex .ires 'l Year From Date Issued <br /> i 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. <br /> EXACT STREET ADDRESS 50,6 S. L CITY/TOWN'(MAIM 04K) <br /> Owner's Name , P.. Phone <br /> Address . 8 . By City (,t}1�L�1c.lT F�EI . <br /> Contractor's Name � , �� <br /> LL Li cense# Z Phone <br /> I <br /> �—S CERTIFICATE OF WORICtiAf!'S COt•1PENSATIO"! IPJSURA"ICE ON FILE WITH SJLHI)? J YES id0 <br /> TYPE OF WORK (Check) : ' NEW WELL 15EEPEN O 1 RECONDITION DESTRUCTION O <br /> t WELL CHLORINATION O WEL LA"BANDONMENT 0 OTHER O <br /> PUMP INSTALLATION O PUMP REPAIREI PUMP- REPLACEMENT <br /> DISTANCE TO NEAREST: :SEPTIC TANK �Q D -rSEWER i.INES /dE PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT? OTHER <br /> PROPERTY LINE -. PRIVATE ..DOMESTI.0 WELL . PUBLiIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ; ,; '4F CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool '� _-Dia, of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing i 412, .� <br /> Irrigation vel Pack Depth of Grout Seal _ y <br /> Cathodic Protection .: Rotary ,Type of Grout <br /> Disposal Other Other -Information <br /> Geophysical �' �n <br /> Surfac6\Seal InSW l.ed b : „r4 <br /> PUMP INSTALLATION: Contractor ;� T <br /> Type of Pump P <br /> PUMP' REPLACEMENT: O State Work DonAe <br /> v „� <br /> PUMP. REPAIR: OState Work 1 3' 1.-40 !t_% { <br />"DESTRUCTION OF WELL: Well Diameter ,� , Approximate Depth <br /> Describe Material d Pr a ure <br /> I hereby certify that I have prepared KteLa-ws , <br /> pplication and that the work will be done in accordance <br /> with San Joaquin County Ordinances , S and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> I certify that in the performance of the work for which this permitis issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of C ifornia. t. <br /> I WILL A A GROUT DCrTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: r DATE:)-LJ-y� <br /> - <br /> (DRAW. PLT L N• -ON REVERS -SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 8Y DATE C(- a&�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II 6IMT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY PATE <br /> � <br /> � i <br />-EH-.1426 Rev. 12-77'.. ,, (�Gh,J�� <br />