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SAN JOAQUIN LOCAL HEALTH DISTRIGI Permit No. <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave: , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 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 descri:bed. - This., application is .made in compliance with San <br /> Joaquin County Ordinance;VNo. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 8618 N. Treasure � Stocktan C CITY/TOWN StoCktnn i <br /> Phone <br /> Owner's Name Dr. Boett er <br /> City <br /> Address . 8618 N. Treasure <br /> Stockton � <br /> Contractor' s Name v��an e reg o a a•. rac. License#�7� I Phone �/6 - 73 1 <br /> IS CERTIFICATE OF wnMIAN' COMPENSATIO"i I1111SURANCE ON .FILE ir1ITFl SJLHD? YES NO <br /> TYPE OF WORK {Check) : NEW WELL CI DEEPEN Q RECONDITION [] DESTRUCTION E3 <br /> WELL CHLORINATION 0---.WELL:�ABANDONMENT-Cl`�"'•OTHE-R-ENT oQ-4 <br /> PUMP INSTALLATION SI PUMP REPAIR❑ PUMP REP <br /> DISTANCE TO NEAREST: SEPTIC TANKd-/O SEWER_-L-I-NE74-4,. PIT PRIVY, <br /> SEWAGE DISPOSAL FIELD" <br /> CESSPOOL/SEEPA E PIT —.OTHER-.- <br /> PROPERTY LIN PRIVATE DOMESTIC WELL Z' PU&LIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 4 <br /> CONSTRUCTIOIV�,Nn <br /> Cable Tool Dia. of Well Ekcavati-dIndustrial Domestic/private: Drilled Dia. of Well.*Casing <br /> Dri ven "Gauge of�-Cas,ing <br /> Domestic/public IrrigationGravel PackDepthof Grout .SealRotar Type ofiGroutCathodic Protection y Other InformationOther Disposal Surface Seal Instal ed <br /> GeophysicalAJ A <br /> PUMP I NSTALLAT,.I.ON: Contractor `a.. _ <br /> H.P. <br /> Type of Pump , <br /> i F E E <br /> PUMP REPLACEMENT: State Work Done :T �mn. e <br /> PUMP REPAIR: I EDState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` . Approximate Depth <br /> Descrjbe Aateria a`ri -Pi oce ure `, t <br /> f <br /> I hereby certify that I have prepared this application and that the Work will be done in accordant <br /> State Laws , and Rules and Regulations- of the San Joaquin Local <br /> with k <br /> Health aDi strguin i ct�— Homeyowner-orCl, censed�-agent' s--s i•gna•tur6`-certi fi-e� the following: <br /> "I cert fy4thA,t;-n thle performance of the work for which this permit is+ issued, I shall <br /> not employ any person i.n-such manner as to become subject to Workman'siCompensation <br /> laws of California." <br /> I WILL CALL A GROU•- - .N- P. - -N PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED TITLE: F DATA:,, <br /> DR W PLOT L N ON REVERSE- SIDE <br /> R"DEP RTMENT U.SE ONLY <br /> PHASE I " DAT <br /> APPLICATION ACCEPTED 8Y - <br /> ADD IT-I-ONAL--COMMENTS:„_ <br /> PHASE I ROUT INSPECTION PHA I I ' INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE g 1 <br /> CU 1A.hr, Qo„ 19_77 <br />