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AIV JUAI UIN .LUUAL HtAL I h U15 I KIL I <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. -7L <br /> Telephone: (209) 4.66-6781 <br /> ---— APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year .From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local " Health" Distri.ct for a permit to construct <br /> and/or install the work herein described. This- application is made in -compliance with San <br /> � doaqui n County Ordinance No. 11862 and the Rules and -Regulations of,the.-San Joaquin Local . Health <br /> District. <br /> EXACT STREET ADDRESS /4�- Z/,?- 61 .. CITY/TOWN SL <br /> Owner' s Name ALL Phone_ gq-eft-ft . q•4_— <br /> AddressSo City <br /> Contractor' s Name A0 tAl License# Z 3 7 Phone 4469,416 Z <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURAINCE ON FILE WITH SJLHD?!. YES NO µ <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPENED RECONDITION Q DESTRUCTION n <br /> WELL CHLORINATION Q WELL ABANDONMENT C3 OTHER ( <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 0 kA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT I :- OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ^Cable Tool Dia. of Well .Excavation:` - 2-, <br /> Domestic/private Drilled Dia. of Well Casing r• i <br /> Domestic/public Driven Gauge of Casing 2 K - <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed1b : <br /> ' PUMP INSTALLATION: Contractor L LtLI t <br /> Type of PumpH.P, O <br /> PUMP REPLACEMENT: ❑ State Work Done Q <br /> - PUMP. REPAIR: ❑State Work Done s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> , I hereby certify that I have prepared this application and that the work wiell be done in accordanc <br /> with"*San Joaquin County Ordinances , _State Laws , and Rules and Regulations of the San Joaquin Local <br /> 7Health 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 shalllf . <br /> not any person in such manner as to become, subject.to Workman.,' Compensation <br /> s of Ca 'i,forn.i_a-7n <br /> I WILL CALLIF `* G <br /> ROLjj ON PRIOR TO GROUTING,AND A FINAL INSPECTION. <br /> SIGNED ' TITLE: ea Y DATE: <br /> ,_-; DRAW PLOT PLAN ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> :PHASE I ' "' <br /> APPLICATION ACCEPTED BY DATE <br /> ►ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -6- 717 <br /> �%l 1,a99Rau 19_77 1/78 2N� <br />