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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No. 72—/ <br /> Telephone:- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -Y-7--T-7 <br /> This . Permit Expires I Year From Date Issued <br /> Complete In Triplicate ' <br /> application is hereby made to the San Joaquin Local Health District fora permitto construct <br /> ind/or install the work herein described.,. This application is made. in compliance with San , <br />'oaciuin County° Ordinance- No. 1862 and the Rules and Regulations of the San: Joaqu_in Local Health <br /> District. <br /> EXACT .STREET 'ADDRESS !2348 N`.. Pi:nasc°o ice. CITY/TOWN Stockton <br /> Owner's Mame Elmer Aman <br /> Phone, 1=12.26: <br /> Address., - Same a City, .5tacktoni.:. i <br /> Contractor' s Name Foothill Drillina Li cense61412 Phone 772-1449 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES XXX NO <br /> TYPE OF WORK (Check) : NEW WELL K1 DEEPEN ❑ RECONDITION ® DESTRUCTION(2 <br /> WELL CHLORINATION Ll WELL ABANDONMENT Q OTHER 0 W <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ PUMP REPLACEMENT ' <br /> it <br /> DISTANCE TO NEAREST: SEPTIC TANK 60 SEWER LINES x PIT PRIVY X <br /> SEWAGE DISPOSAL FIELD 75- CESSPOOL/SEEPAGE PIT 100 OTHER X: <br /> PROPERTY LINE40 PRIVATE DO ESTIC WELL 25- --- PUBLIC DOTIESTIC. WELL --&- <br /> INTENDED USE i, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �i X Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing 6' <br /> Domestic/public Driven Gauge of Casing 10 . <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection Rotary Type of Grout Cement <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b D rill:er <br /> P NSTALLATION: Contractor <br /> Tyof Pump— <br /> pe ' <br /> PUMP REPLACEMENT: [] Done <br /> PUMP REPAIR: O State Work Don <br /> i <br />` DESTRUCTION OF 'WELL: We er ioximate Depth <br /> escribe Materia 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 /,A <br /> laws of Califo � <br /> II WILL CALL UT 'INSPE OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Owner DATE: 3 $ 79 <br /> UKIAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTME - USE ONLY <br /> II <br /> PHASE I � DATE 3 <br /> APPLICATION ACCEPTED BY : <br /> ' ADDITIONAL COMMENTS: .I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION 8 DATE _ INSPECTION 8Y DATE: <br /> eu ii�c 0, 1 17-7 4 <br /> _. $ 21L. <br />