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--avAK.o,1*4tX SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.ZX-14_ss <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued&-75'_ <br /> This Permit Expires 1 Year. From Date Issued. <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local .Heal_th .District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health <br /> District. (5�wrIptve <br /> EXACT STREET ADDRESS __11&: / 6o;!a,0_ 7� — r CITY/TOWN <br /> Owner's Name Phone <br /> Address f�Q h �r19Yc�`a �r��rrt -_ _ _� City + <br /> Contractor' s Named License#19,3 2L hone 1 —79 7 <br /> IS CERTIFICATE OF WORKMAN'S QIANSATION INSURANCE 0M FILE WITH SJLHD? YES 1,40 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN O RECONDITION ® DESTRUCTION M <br /> WELL CHLORINATION n WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> K Irrigation Gravel Pack Depth of Grout Seal � . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP. INSTALLATION: Contractorc.-, <br /> Type of Pump H.P. �L <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: (J-DState 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 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 <br /> laws of California. " <br /> I WILL CAL FOR A GROUT I CTI RIOR GROUTING AND A FINAL INSPECTION. <br /> SIGNS —,z2-Z TLE: DATE: <br /> (DRAW POT PIAWON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Zyc-- DATE --1.;,-41'7,F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I UJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S7/ �y <br />-EH 1426 Rev. 12-77 1/78 2M <br />