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)6 SAN SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOR 60 Hazelton Ave. Stockton CA 95205 Permit No. <br /> ICI: USE: 1 1 E <br /> Telephone: (20 9) 466-6781 <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT Date Issued GD 3D-� <br /> This Permit Expires 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/br 'install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 7.862 and the Rules and Regulations of -the San Joaquin Local Health <br /> i <br /> District. <br /> EXACT 'STREET ADDRESS y 1,41 F CITY/TOWN 4- cCc ' <br /> Owner's Name c�. Phone <br /> Address City ,GIGva e <br /> Contractor's -- <br /> Name Li ense#2!3 7Zs�hone y <br /> IS CERTIFICATE OF WORKMAN'S COMI NS I0IN INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE -OF WORK .(Check) : NEW WELL❑ DEEPEN ❑ RECONDITION-C3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 09 PUMP REPLACEMENT [I <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 SPECIFICATIONS' 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing E <br /> Domestic/public Driven Gauge of Casing i <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contracto r <br /> Type of Pump .�✓ H.P. 4,e-6 - - <br /> I <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP. REPAIR: WState Work Done4- <br />'.DESTRIICTTON-OF:-WELL: ­We11 -Diameter `- '' TMApprox,imate-Dep'th-- �— <br /> Describe Material and Procedure <br /> I` 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 Loc <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 INSPECTI P I 0 GROUTING -AND A FINAL INSPECTION. _! <br /> SIGNEDTLE: �v,o1' DATE: <br /> JDRfAW4P00T±—PL*AWON' <br /> REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br />, APPLICATION ACCEPTED BY' DATE <br />,' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE All FINAL INSPECTION <br />` INSPECTION BY DATE INSPECTION BY DATE <br /> i rp 1a9r, Pc►v 19_77 <br />