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SAN JUAQU1N ,LUUAL,HEAL1H U15IKILI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -X ,3 a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT Date Issued.,--,'-/1- - � <br /> This- Permit.-Expires I Year From `Date Issued <br /> Complete _In Triplicate <br /> . Applicati'on 'is hereby made to the San Joaquin Local Health District for a permit .to construct <br /> and/or install the work herei-n described. ' This. application is made in with San <br /> ,'oanuin County Ordinance-.`,0. ;1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSCITY/1001 <br /> k <br /> Owner' s Name 64 ' �� Phone / ,. - 7 <br /> f Address l Ci ty - AIV <br /> -Contra-ctor's-� a a -- v � License : Phone I'=�� s' _ <br /> IS CERTIFICATE OF WORKMAN'S COP1PEtJSATJON IPJSURA?10E ON .FILE Ir1ITFl SJLHD? YES NO ✓rf <br /> . TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ['� DESTRUCTION <br /> + WELL CHLORINATION 0] ,WELL ABANDONMENT ❑ f OTHER 0 <br /> PUMP INSTALLATION ZK PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 'OTHER x <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I.ndustrial--7 Cable Tool Dia. of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r. '6 <br /> Disposal ('Ether Other Information- <br /> Geophysical Surface S 1 Installed by: <br /> PUMP INSTALLATION: Contract -r-) <br /> Type of Pump___,j k H.P. <br /> PUMP REPLACEMENT: 0 State Work Done � <br /> PUMP REPAIR: CDState Work Done <br /> "DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this applic6ti,on and that the work will be done in accordanci <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed a9ent' s;:signature certifies the following: <br /> I certify that in the performance of the work for--which this, pprmi't, 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 CAL FOR A GROUT INSPEC IO � PRIO 710 GROUTING ANDFINAL„INSPECTION, <br /> SIGNED L/ �� TITLE: 6'2� DAT A', ,` <br /> J <br /> (DRAW PUT PLAN ON REVERSE SIDE <br /> FORD PE -USE ONLY k <br /> 1PHASE I r . <br /> ,APPLICATION ACCEPTED DY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II+ F AL ;INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE <br /> .1EH 1426; Rev. 12-77 <br /> 1/78. 2M <br />