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SAN JOAQUIN LOCAL HEALTH DISWIC1 <br /> R_QF^ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> F r� Date Issued Z-//- <br /> APPLICATION OR WELL CONSTRUCTION OR RUMP PERM_ , <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/car install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET AQDRESSaSe Z�& �T^ ��, CITY/TORN Ic 1�16114 <br /> Owner's Name /� Phone 173 i <br /> Address - City Sr4 <br /> Contractor' s Name y t 'jvjr/? License Phone <br /> - <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATTO"f T"SSU ANCE ON FILE WITH SJLHD7 YES '10 <br /> TYPE OF WORK (Check) : NEW WELL U0 DEEPEN ❑ RECONDITION CD DESTRUCTION[� <br /> WELL CHLORINATION C] WELL ABANDONMENT [- OTHER 0 - <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK/oQ I SEWER LINE$_V)'+ PIT PRIVY v <br /> SEWAGE DISPOSAL FIELD j CESSPOOL/SEEPAGE PIT — OTHER <br /> PROPERTY LINEM-`PRIVATE-DOMESTIC WELL - PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation .42 " <br /> 7-'—Domestic/public <br /> Domestic/private Drilled Dia. of Well Casing ., <br /> Domestic/publ i c Driven Gauge of Casing <br /> Irrigation _Gravel Pack Depth of Grout Seal �Sr; <br /> Cathodic Protection _Rotary Type of Grout rle Ad-c.d t - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ _ _..H.._p_ <br /> PUMP REPLACEMENT: �] State Work Done � <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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, 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 OR A G UT INS ECT ON BR1XR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE; <br /> r g A . DATE <br /> W PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c'% £ �'j/7ff <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASFIN SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6-13-79 <br /> EH 1426 Rev. 12-77 1/78 2M <br />