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SAN JUAQUIN LUCAL HEAL I H U1J i RIR I I ----� <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.77 <br /> Telephone: (209) 466-6781 <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From .Date Issued <br /> r 4 Complete In Triplicate) /.A� 7�i'J <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 /> Joaquin County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> D4strict. <br /> EXACT STREET ADDRESS Uh CITY/TOWN <br /> Owner's Name . Phone 613 , _&e , <br /> Address .Sg ». City .� <br /> Contractor's Name , LicenseL.�/Q _ Phone <br /> ?S CERTIFICATE_ OF t,COf'1<t1AN'SCOFIf.ENSA.I.O;I.�_I."1S_L'l;A�fOE OrI�FI.LE 1�1ITFf_SJl HD?�.. YES . w ty0 <br /> TYPE OF WORK (Check,) ,NEW WELL.b DEEPE=N 0 RECONDITION ❑ DESTRUCTION❑ ` <br /> "WELL"'CHLORINATION`O -WELL ABANDONMENT ED OTHER rJ <br /> PUMP INSTALLATION S& PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE -PIT. OTHER C <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE . 4 TYPE OF WELLCONSTRUCTION SPECIFICATIONS .-S <br /> Industrial Cable Tool Dia. of-Well Excavation N <br />- Domestic/private Drilled ,,Di-a. ,of WelJ Casing'—,Domestic%pu151 A C- ri v auge of=Casing <br /> Irr_igation�' -�., � , 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: Contractor <br /> Type of Pump H.P. J <br /> PUMP REPLACE=MENT: Q State Work Done <br /> PUMP REPAIR: -❑State Work Done <br />`•DESTRUCTIGN'OF-WELL:: .-`Wel l- Di-meter Approximate Depth `— '"°" <br /> Describe Materia and Procedure <br /> F <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-Hone TM,owner"-_6 Vicensed agent' s .signature certifies the. fol 1 owi rig <br /> "I certify that ni .,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 i <br /> laws of California. " 4 <br /> I WILL CALL EAR A GROUT-ASPEkTION PRIOR TO GROUTING AND AFININSPECTION. <br /> SIGNED TITLE: DATE: I--�5 <br /> ► <br /> (DRAW PLT PLTN ON REVERSE SIDE �i <br /> PHASE I FOR DEPARTMENTUSE ONLY ; <br /> __ <br /> APPLICATION A6CEPTED ,BY. DATE %r 7 7 <br /> ADDITIONAL. COMMENTS: <br /> PHASE :II GROUTnINSPECTION PHASE TTI FINAL INSPECTION <br /> ., <br /> INSPECTION BY DATE; AAV INSPECTION BY DAT£/ <br />.EH:1426 Rev_ 12-77 T i-7o �� <br />