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SAN JOAQUIN .LQCAL,. HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209). 466-6761 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/p-3-2,5' <br /> This Permit Ex ices 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 incompliance with San <br /> ,oaqu,On County Ordinance No. 1862- and the Rules and Regulations of .the: San Joaquin Local Health ` <br /> Distr'ct. 0 .. 14!6116 A-Y , <br /> EXACT STREET ADDRESS/rp,v CITY/TOWN ��7 <br /> Owner' s Name a 6,icz Phone 4';?/- 3/&f <br /> Address-Q_ <br /> Contractor's Name . 4 License# Phone e <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSUR 110E OPJ FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN [I RECONDITION ] DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 C <br /> PUMP INSTALLATION Q Pl1MP Rt"P.A1Ri PUMP REPLACEMENT ED q�> <br /> DISTANCE TO NEAREST: SEPTICTANK-, In( SEWER LINES PIT PRIVY,_ <br /> SEWAGE DISPOSAL F1 CLD —CESSPO,QC/SEEPAGE PIT OTHER F <br /> •� PROPERTY LINE-- PRI-VATE 'DOMESTIC" WELL PUBLIC DOMESTIC WELL - -. -- , ° 4 <br /> INTENDED .USE' ' -;J-' TYPE%'OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation z. . <br /> .Domestic'/private k. n3� Drilled Dia. of Well Casing <br /> Domestic/pudic 1.71 <br /> .° Driven Gauge of Casing <br /> _ , 1 rigation' �- Gravel Pack. Depth of Grout Seal <br /> Cathodic protection rt Rotary Type of Grout <br /> Dispo'sal.' 'I �1 Other Other Information r ' <br /> __N Geophysical l 7t4 Surface Seal `Installed by: <br /> PUMP IINSTALLA"TP"ON: Contractor I Pew yr '` <br /> Type, of u m -� _ H,P.fir <br /> PUMP REPLACEMENT: [3-State Work Done <br /> PUMP REPAIR: QState Work,,Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Approximate Depth <br /> Describe Material 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. 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 i <br /> laws of California. " <br /> I WILL CALL FOR A GROUT JNSPECTION PRIOR TO GROUTING AND 6 FINAL INSPECTION. <br /> SIGNED T I T L zisd —�I DAT �2�. <br /> DRAW PLOT PLN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE /d <br /> ADDITIONAL COMMENTS: �:.:...._ . . <br /> PHASE II GROUT INSPECTION . .1, 0PHAK III IN L INSPECT-I-ON <br /> INSPECTION. BY DATE. <-NS-PE_CTION,F ATE .� <br /> 1 /7A 7M <br />'SW 1 d7F. Dai, 1 9_77 <br />