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SAN JOAQUIN LOCAL HEALTH 01STRICT <br /> FICE USE: 1601 E. Hazel Von Ave. ; Stockton, CA 95205 Permit No.»_1,2f'p <br /> _ Y Telephone: (209) 466' 6781 <br /> ' Date Issued <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP 'PERMIT <br /> a <br /> This .Permit Expires 1 Year From Date` Issued <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 workl1here.in described. This application is made in compliance with S'an <br />$ Joaquin County Ordinance No. 1862 and the Rules and Regulations of- the San Joaquin Local-Health <br /> Di5tr.ict � <br /> • <br /> EXACT- STREET ADDRESS :.,ri CITY/TOWN <br /> Owner' s Name r �M. �� ctr-t i Phone <br /> Address // k . ` R , � Cityssi4 . .,:�' <br /> Contractor's Name License# one ��,. —' 6 - <br /> ' IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN 'INSURANCE ON FILE WITH SJLHD? 'YES NO <br /> TYPE OF WORKCheck : � NEW WELL - F . <br /> } yh . Q DEEP EN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> F WELL CHLORINATION ❑ .- WELL ABANDONMENT a OTHER ❑ <br /> PLUMP INSTALLATION C! PUMP, REPAIRS . PUMP-,REPLACEMENT [] <br /> q <br /> DISTANCE 'TO NEAREST: ASEPTIC TANK SEWER LINES ' PiT PRIVY.;. • ` '- ",. <br /> �SSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT OTHER ' <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ; PUBLIC DOMES1=lC WELL4_ ___ <br /> �. . <br /> INTENDED USE <br /> y' TYPE OF WELL- ' "C0�l51'RUCTION SPC3FICATIONS - <br /> 4, Industrial Cable Tool , Dia. of Well Excavation , <br /> 77—Domestic/private: Drilled, Dia. of Well Casing ' <br /> Domestic/public Driven I. Gauge of Casing <br /> ` Irrigation. Gravel Pack Depth of Grout Seal a,. . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical` Surface Seal Installed by: CR <br /> PUMP INSTALLATION: Contractor "' 3 -- <br /> Type of Pump H.P. <br /> PUMP- REPLACEMENT: ❑State Work Done <br />[ PUMP Rift: :.❑State Work Done � ,,, /1.,,� „,� <br />; DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i II <br /> I hereby certify thatI have prepared this application and that the work will be done in accot-_ nLE' <br /> with San Joaquin Co`untyOrdinances , State Laws , and Rules and' Regulations of .the San Joaquin Local <br />' Health District, Home owner or licensed agent' s signature.'certifies" the- following: <br /> Y F <br /> "I certify that in ttike .performance of the work for which this permit is issued, I shall <br /> F not employ any persa:n in such manner as td become subject to Workman's Compensation <br /> laws of California. ' <br /> I WILL CAL FOR A GROUT !INSP 0 P TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED RITLE : = � f' DATE: <br /> IMr RAW PLOT PLAVON REVERSE SIDE <br /> FOR DEPARTMENT 'USE. NLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY �' a•, DATE <br />' ADDITIONAL COMMENTS: :11� <br /> PHASE II GROUT INSPECTION PHASE , III FINAL INSPECTION <br /> INSPECTION BY ,113 DATE INSPECTION BY L,—\ DATE \j� <br />,EH 1426_ Rev . 12-77 :,� 1 /7R ,M <br />