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a <br /> SAN JOAQUIN,:4L'DCA.Lr.iEALIH iJ YMMI <br /> OFFICE USE: � " X1601 E. Hazel}ton' Ave: Stockton, CA 95205 Permit No. <br /> Telephone-:,, :(209) 466,k6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - - <br /> r Thi sr`Permiit Ex 'ares �"''bar. From .Date' Issued . . n <br /> 4 Complete.,I.h Trip. i.tate , ' w <br /> Application is hereby made to the San Joaquin­Local 'Heal,t'h.,District -for a permit to construct <br /> and/or 'install theF;work here i:n .descr:i'.bed: . Th'fis, app-lication ,is{made in compliance -with' San <br /> ,'oaqui n County=,Ordi-nance­-No., 186.2 sand :the Rules and,Regul;ati ons,,of the,,Sa.n,.Joaqu n. Local .Health <br /> District. <br /> 'r�. <br /> a <br /> EXACT'°STRET'Adid RESS � ° ,pC �/ _� CITY/TOWN <br /> ' Owner's Name ,11 �.. Phone: <br /> k Address City/r <br /> Contractor' s name ldh�AIJrl=,! 2a 2d. - _ - License# . Phone 3/, Z <br /> ?S CERTTF'ICATE OF WORKMAN'S 'COMPENSATIO�! INSURANCE ON FILE WITH SJLHD? YES 1140 <br /> I TYPE OF WORK (Check).: NEW WELL R DEEPEN ❑ RECONDITI:ON Q DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT a OTHER 0 <br /> F <br /> PUMP INSTALLATION 4 PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL .FIELD�s� � CESSPOOL/SEEPAGE PIT 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 /1 <br /> 4.--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge:.-of Casing . 1-2' <br /> Irrigation �-Y- Gravel Pack -Depth of''GroutSeal <br /> Cathodic Protection ' 'jam_=»Rota'ry =Type. :of--Grout q _ <br /> h s 'Disposal 0thd..r Other Information's <br /> 7 Geophysica_l ti . x v w:- Y -- ' Surface_Sea1<Instal-Ted—by.; <br /> h <br /> *' -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: M State-~Work Done <br /> PUMP REP I �❑'State Work Done <br /> DESTRUCTION OF WELL: / "Well Diameter � Approximate Depth �F <br /> Describe Materialan .. Proce. ure <br /> I hereby certify that I. have,,p pared this application ,and that the work will be done in .accordan <br /> with San Joaquin County Ordinances , State Laws , and 'Rules and Regulations of the San Joaquin Loca <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 Californ'ia. " <br /> I WILL CALL R GROUT"INSPECTION PR GROUTING AND A FINAL INSPECTION. . <br /> I SIGNED TITLE: DATE: <br /> (DRAW PLT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' i - <br /> APPLICATION ACCEPTED BY::j]a ;; ,` = '% �;' DATE21 <br /> ADDITIONAL COMMENTS:.,.. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ``T-NS-PI CTI-4N1 B-Y ---= DATE �, --.4 - � ,� � I:NS.RECTTjpN-_BY ATE <br /> /78 __2MrEH1426 Rev.. 12-77 w1 <br />