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CO.4" �Fo~f SAN JOAQUIN LOCAL HLALIH U1SIR1L1 <br /> ICE USE: 1601 . Hazelton Ave. , Stockton, CA c 95 Permit No.7� <br /> Telephone: (209) 466-6781 -, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> This Permit Expires 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 in compliance with San <br /> 'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. las-a-� F h7,> .H Co//0 vi& Sc/0r--C <br /> EXACT STREET ADDRESS W.F. li,r.,mY e4e Ju Tnn < R&r,bar# Pi( CITY/TOWN <br /> Owner's Name__ M,?CV - n Phone <br /> Address /1 / 6elel.I) r,- City C*6 4�-, <br /> Contractor's Name �,J License# /y37k,L Phone C/61 -7C 7� <br /> IS CERTIFICATE OF WORKMAN'S COMPEL ATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT ❑ <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 i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> __Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �_��C/�.,>DG/ .a�) <br /> Type of Pump ` aShOl &A�-Q _/Ci H.P. ice_ <br /> PUMP ® State Work Done �w�los// Ale <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 accordant <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 INSBgtTJVV P GROUTING AND A FINAL INSPECTION. -y <br /> SIGNED , TLE: 61 DATE: <br /> 6 R W PLOT PLAW ON REVERSE SIDE <br /> PHASE I R DE AR MENT USE ONLY <br /> APPLICATION ACCEPTED Y DATE 12 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ? j/{�{/✓1� <br /> =H 1a9r, Pa. 19_77 <br />