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+ SAN ,l OAOU I N LOCAL H CALT-H OI STR I C7 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205. Permit No. - ,Jo <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -Q-�1 <br /> This Permit Expires 1 Year From Date__Issued 7-16 L , d�► <br /> Complete. In Triplicate „-r3e ��i <br /> Application is hereby made to the San Joaquin Local Health District for a p "+emit" trod o struct <br /> and/or install the work herein described`. This application is made in compliance with San <br /> ,.oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS F_ HtA_)�/ ` a - CITY/TOWN V'nc:�r )Jr_CCS <br /> Owner's Name C)") 1<3U -F ��� _ Phone <br /> Addres' 2__E_ LA-) I aO cityT c�1c 11 Ccs_ <br /> Contractor' s Name_Ofxln ; License# ' Phone y l <br /> IS CERTIFICATE OF WORKMAN'S M11PENSATION INSURANCE ON FILE WITH SJLHD? YES t/ NO <br /> TYPE OF WORK (Check) : NEW WELL Ca— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ IN. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> .PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7/0d' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1,E4 , CESSPOOL/SEEPAGE PIT OTHER ; 11 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> yVomestic/private t/ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i/Gravel Pack Depth of Grout Seal <br /> Cathodic Protectiony- Rotary Type of Grout P - •ft <br /> Disposal Other Other Information , Y;C 1��, _ <br /> Geophysical Surface Seal Installed b i-illc,r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: FJState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. i <br /> SIGNED i �1_ rr i. :1 CW �. � DATE: 7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS - , <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION INSPECTION BY DATE —/ <br />£H 1426 Ray_ 1 2_77 /�D ��( -�7S ° ' "' �C rd 7 1 /7.$_ 2 M <br />