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SAN JOAQUIN kOCAL HEALI-H UISIRI0 <br /> FQR FFJCE. USE: 1601 E. Hazelton Five. , Stockton, CA 95205 Permit No.�74.__S-ol <br /> Teleph,ne: (209) 466-6781 <br /> � n Date Issued 1-14-29 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This . Permit- Ex ires I Year 'From Date Issued <br /> Complete I'n Tri pticate ' <br /> Application is hereby made to the San JoaquinLocal Health District for a_, permit to construct <br /> and/or. install themwork .herein described. This application is .made in compliance with San <br />� doan,jin County :.erdinance No. _1.862 and the .Rules and Regulations of the San Joaquin Local Health <br /> District. ' <br /> EXACT 'ST.REET ADDRESS <br /> Owner' s Name- Phone <br /> s� <br /> AddressCi ty �{ . <br /> Contractor's Name icensef Phone <br /> IS CERTIFICATE OF WORKMAN'S ENSATIO"� <br /> INSURANCE <br /> f- , FILE WITH SJLHD? No <br /> - <br /> TYPE OF WORK (Check) : NEW WELL 6--'DEEPEN ❑ RECONDITION ❑ DESTRUCTION n� y� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> E PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> F <br />'` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL. -mt, —CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 Excavation ri <br /> c/Domestic/private Drilled Dia. of Well Casing <br />' Domestic/public Driven" Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �otary Type of Grout <br /> Disposal Other Other Information -- <br /> Geophysical k Surface Seal InstalTed by: ,, <br />! PUMP INSTALLATION Contractor <br />' ! Type of Pump H.P. <br /> YPUMP REPLACEMENT: } []State Work Done <br />; PUMP REPAIR: p State Work Done <br /> DEmSTRUCTmI`ON OF' WELL: 'Well Diameter F i Approximate Depth <br /> Describe Materima -ard-Procedure - <br /> i i <br /> I hereby certify that I have prepared this_app!-i-cation 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 Mowner 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 a=y—any person such manner as .to become subject toWorkman' s Compensation <br /> 1 orni <br /> I W L CALL F A G UT SP CTIO TO GROUTING AND FINAL INSPECTION. <br /> S NED TITLE: ` DATE: <br /> -- -(DRAW PLOT PL N ON REVERSE` IDE <br /> # t FO DE M T U E , <br /> 1PHASE I 4 _. <br /> APPLICATION ACCEPTED .BYE DATE ' <br /> ADDITIONAL COMMENTS: .`• / <br /> M PHASE II- GROUT i PECTION � ''�` PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE f-7�7 INSPECTION BY 2:3DATE --H 1h26 .. ReV.� Y2-77 <br /> 78 -2M <br /> �` <br />