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i SAN JOAQUIN,-,LOCAL HEALTH MIRICI <br /> Stockton, CA 95205 Permit No. 7�-S8S <br /> FOR OFFICE USES 1601 E. Hazel;ton.�Ave. , ; _ <br /> M ; Telephone. (Z0 ) 466,-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION PUMP PERMIT Date Issued <br /> This `Permit Exp ires 1 Year From Date`Issued ' ' <br /> f.: <br /> (Compl'ete In Trip i'cate) " <br /> '•''�.a_.� .. :s ..gyp . .. .,...� *,. Y` -:. 1 . `- �- + ::.i' t.- . -)-',._ <br /> Application -is hereby made to the San-Joaquin, Local , Heal:th. Distr ct :for.,a permit ,to iconstruct <br /> and/or,_ ins to 1.1 ,the:work :here i n .descr:i.bed.. T'hi sappl,i cati on i s:made i n .compliance '.with.San. <br /> ,'oaqu i n-.County,;Ord nancg ;Ido;; 1 62 ,and the'.;Rul;es`,,anal,.Reg.ul ati o,ns..of the, San Joaqu i n Locale Health <br /> 4 Cistrict. « <br /> EXACT' STREET CITY/TOWN <br /> Owner's Name G Phone <br /> Address tYac�. <br /> Ci <br /> F Contractor's Name ` �� License# Phone -2- <br /> 1S CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURA*lCE ON FILE WITH SJLHD? YES NO- <br /> TYPE OF WORK (Check) : NEW WELL ia" DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑. � <br /> WELL .CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ga` PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST:: SEPTIC TANKZZQ, SEWER LINES_ PIT PRIVY 71 <br /> SEWAGE DISPOSAL FIELD /S�O. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATff 0OMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> L,--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Awt. <br /> Cathodic Protection 1--Rotary , "Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor'JA% 124212 <br /> Type of Pump H.P. <br /> w <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑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 accordani <br /> with San Joaquin County Ordinances; State Laws , and -Rules and Regulations of the San Joaquin Loca' <br /> f 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 /> F not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. ' <br /> I WILL CALL MR &-,GROUT -INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: x/, <br /> - <br /> y (DRAWkPLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ,: . ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION VPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7—/ _W, 29 <br /> t,: EH 1426 Rev. 12-77 _ R. . . 1 <br /> /78 - 2M <br />