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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton&Ave:`;" Stockton, CA 95205 Permit No., <br /> Telephone: (209) -466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_�/_ga_, <br /> This Permit. Ex ires 1- Year From Date Issued <br /> =Q .complete In Triplicate �C-7 _ o�,ori so' GS <br /> Application is hereby. made to the San Joaquin:. Local Health Distri.ot for a permit :to construct v <br /> and/or install the work herein described. This application is made in compliance with San 4 <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health' m <br /> District. MILE iii-l_^/�S i D� !�'v,��i 91 001 % <br /> EXACT STREET ADDRESSiS_ _ CITY/TOWN <br /> Owner's Name` :F ',�'�"` Phone - <br /> Address - �. _ CitYC'a/-:��Z? �# <br /> Contractor's Name l GLicens �a� `Phvn.e ��7'�SF. �_ . <br /> IS CERTIFICATE OF WORKfiAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL Ua-�' DEEPEN [�1 RECONDITION © DESTRUCTION[ <br /> WELL CHLORINATION Q WELL ABANDONMENT OTHER 0 4. ' <br /> PUMP INSTALLATIONS PUMP REPAIR❑ PUMP REPLACEMENT <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK. U ,lE' SEWER LIKES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C°ESSPOOL/SEEPAGE PIT OTHER " s <br /> PROPERTY LINE' -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 'WELL <br /> INTENDED USE TYPE OF WELL ' -...'__- CONSTRUCTION SPECIFI6ATIONS <br /> Industrial Cable Tool' ,3 Dia. of Well Excavation "_ t <br /> f Domestic/private Drilled - -.. Dia. of Well Casing_Domestic/public Driven Gauge of Casing <br /> k ­,*Irrigation Gravel Pack Depth of Grout Seal' <br /> _Cathodic Protection Rotary .,� Type of Grout <br /> Disposal _ Other �.,� .Other Information t <br /> Geophysical Surface_ Seal Installed by: f <br /> PUMP INSTALLATION: Contractor �,J 11c <br /> Type of Pump H.P. <br /> PUMP -REPLACEMENT: p State Work Done <br /> PUMP REPAIR,: QState Work Done_ 1j / 9,LG /},�/L�l/ aze_- SrIjA <br /> DEST.RUC ION'_OF WELL:.,..• We.11 Diameter _-__Ap.pr-oximate_De.pth'^.' j,)_ <br /> Describe Material a-nd Proce ure- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <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, Iishall <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California." <br /> I WILL CALL7,PU A ROUT IN-SPECTVN PRIOR TO GROUTING AND A FINAL INSPECTION. � <br /> SIGNED .✓ TITLE: DATE: <br /> -(DRAW PLOT PL N ON REVERSE IDE <br />)HASf I FOR DEPARTMENT USE ONLY <br /> VPPL1CATIONi ACCEPTED BY 22 DATE ��-Z R' <br /> kDDITIONAL-COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D&TE T 7 <br /> N 1426 __ 17ey-. 12-77 .-.--- 1/78 2M <br />