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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, _2. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_'Z-5- ?9 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a per it 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' Regu,lations of the San Joaquin Local Health <br /> District. . <br /> ,EXACT STREET ADDRESS 11 0 `Grant bine Rd. Trac CITY/TOWN <br /> Owner's Name Tracy Assoc! 1 2Phone 415 886 5669 <br /> Address 2924 Palamares Rd. Castro Valley Cit <br /> Contractor's Nam&lean Martell & Son Inc. License#296448 Phoni4l,5 432 4282 <br /> 4,4 <br /> IS CERTIrTrATE_O.F...WORKr.IAN'S-YCO�IPENSATION-I,NSURA"iC£ ON`"FILE WITH SJLHD? YES �' <br /> 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITIONDESTRUCTION E2. �5 <br /> WELL CHLORINATION © WELL ABANDONMENT OTHER 0 —� <br /> PUMP INSTALLATION,[ PUMP REPAIR0- - PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK ukn SEWER LINES.ikn PIT PRIVY ukn <br /> SEWAGE DiSPOSA IEL CESSP OL/SEEPAGE PIS^' OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC D MESTIC Wim` <br /> ' INTENDED.USE ' TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> In ustr a Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic%publicDriven Gauge of Casing <br /> „ E <br /> _ Irrigation Gravel Pack Depth of Grout Sea <br /> _______Cathodic Protection Rotary Type of Grout <br /> _Disposal t Other Other Information <br />______Geophysical Surface Seal Inst a ed <br /> PUMP INSTALLATION: Contradtor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> RUMP REPAIR:- A - EState Work Done—R= <br /> --- <br /> 4ESTRUCTION 01 WELL: Well *Diameter'' T _ Approximate Depth <br /> { Describe Materia and Proce ure <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 />[ WILL CALL FOR A GROUT INSPECTIO PRIOR TO GROUTING AND A FINAL INSPECTION. <br />:I_GC�E_D�:_..,.,�,� i TITLEPress <br /> D P L N ON REVERS>� SIDE DATE. F <br />'HASE I R DEP RTME USE ONLY <br /> iPPL II'CATI ON ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION 8Y C14 � AT£ � 1 ; <br /> H: 26 Rev, '9/7$ _ 9/ <br />