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r SAN JOAQUIN LOCAL htAL-1 H�11M I RIS i <br /> ��QF1 %C U� SE:. 1601 E. Hazelton Ave. , Stockton, CA. 95205 Permit No:Z��.� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date IssuedMAY 2 4 1978 <br /> This Permit, Ex ires 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 work herein described. This Application. is made in compliance wi-th San <br /> 4oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS `S RC1 � `�'' MA X31 <br /> CITY/TOWN <br /> Owner' s Name 7J AE� 7 t9 N 0-0 Phone <br /> Address City 7:�C557 I <br /> Contractor' s Mame License#./ S hone 4 <br /> _'S. CCRTiFICATE OF WORKMAN'S C0,11PENSATI01"I INSURANCE ON FILE WITH SJLHD? YES 1140 + <br /> f <br /> TYPE OF WORK Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT U OTHER 0 per, <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT �1J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFJCAT,IONS <br /> Y Industrial Cable Tool Dia. of Well Excavation <br /> r`V `Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b 2- <br /> PUMP INSTALLATION: Contractor_ � �'S <br /> Type of PumpH.P. <br /> 11. <br /> PUMP REPLACEMENT: E] State Work Done <br /> PUMP REPAIR: Q State Work Done <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 will be done in accordant( <br /> with San Joaquin County Ordinances , 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 /> "I certify that in 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 Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A' GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: 5-- <br /> DRAW PL T PLTN ON R E V E R A SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE S- <br /> ADDITIONAL C <br /> P PHASE II I AL INSPECTION <br /> INSPECTION B ATE", INSPECTION 8Y ' ATE 8'V-'15�' <br /> FH I A2F Poll 19_77 '1 1-7n nii <br />