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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIC SE: 1601 E. Hazelton Ave. ,.-Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit 'EX1re-s- 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/or install the work herein described. This application is made in compliance with San' - <br /> ,'oaquin County Ordinance No . 1862 and the Rules and Regulations- of :the San Joaquin Local Health <br /> 5iStr ct. <br /> EXACT STREET ADDRESS 46 N ,�E•t 2 Gam' CITY/TOWN,' mac/ <br /> Owner' s Name <br /> M r, JL T/"96/1/ Phone ca <br /> Address F4/4 AA diLrr Ge D. City. c <br /> Contractor' s Name . !?/,CLy Dfzi4 ,� i .u6 License# ����� Phone ?�e�f= /� 7 1 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURXNCE ON FILE WITH SJLHD? ''YES 1O_X_ <br /> TYPE OF WORK (Check) : NEW WELL a DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br />! PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK/50/ SEWER LINES/7 5i PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CCS—SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL_Lny__� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /'/ X2, <br /> Domestic/private Drilled Dia. of Well Casing j a " z 1_• , <br /> Domestic/public Driven_ - Gauge of Casing e �. <br /> E Irrigation Gravel PackDepth of Grout Seal <br /> Cathodic Protection Rotary Yh Type of Grout <br /> Disposal Other = , Other Information -- <br /> Geophysical ,,,. _- n-surfa.ee Seal Installed by: <br /> PUMP INSTALLATION: Contractor c/d_J �P(A ray E <br /> Type of Pump H.P. <br /> x <br /> PUMP REPLACEMENT: 17 State Work Done <br /> PUMP REPAIR: ❑State Work- Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 7 <br /> Descri Mat ial an ro edure <br /> k <br />� I hereby certify that I h ve p axed 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 /> notemploy any person in such manner as t"o become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t TITLE: C'o-- DATE: -5- 3o <br /> k <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI ' <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL -COMMENTS-; ­ - <br /> PHASE__I I_.GROUT__INSP.E.CTI.ON ___._ .. _ _ w PHASE I I F NAL INSPECTION <br /> INSP CTION BY A DA INSPECTION BY - DATE <br /> T2m, <br /> AFH 1499, av- � 9_77 <br />