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e.SAN JOAQUIN .LOCAL.: HEALTH DISTRICT <br /> F1=ICE USE• 1601 E. Hazelton; Ave. , Stockton, CA 95205 Permit No. 7r <br /> Telephone: .. (209) 46676781 S� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permi t�Exf i res' 1`�Year "From Date `"tssued <br /> - c.,-r,��",��.7, _ Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District foraerm- <br /> -it .to.construct <br /> p <br /> and/or install the work herei rill-descri bed... Thi s appl i-cati on .i s made in compliance with San <br /> Joaquin .County -Ordinance! No. 1862 and the Rules. and Regulations.' of the San Joaquin. Local Health <br /> District. ick 2fq��ig5u�j ��Cis , . # <br /> U CQu <br /> �S�S .� �' S Y/TOWN SAG� ( f/ <br /> EXACT STREET ADDRESS � <br /> Owner's Na ! RdAZC2e c� (` , Phone_ x'17 4(y fyp <br /> Address C� .,. >�e �oG Ci ty <br /> Contractor' s Name � ]x ILI 1, r, �s License#�¢/Z3 M(,Phone '964- l 7�Z3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I"JSURA"!CE ON FILE WITFI SJLHD? YES �^ 'd0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION[] <br /> WELL CHLORINATION p WELL ABANDONMENT [ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR p PUMP REPLACEMENT [I . <br /> ., <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .1 Rotary Type of Grout <br /> Disposal " . A Other Other Information ��.. <br /> Geophysical Surface Seal Installed by: � <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump H.P. <br /> 41, <br /> PUMP' REPLACEMENT: a State Work Done <br />,PUMP REPAIR: QState Work Done -' k <br /> DESTRUCTION OF WELL: Well Diameter Approximate De th <br /> Describe Material and Procedure <br /> 1 1 <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 Locale <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 FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED cZW, TITLE: 6)l DATE: F-C ' 79 <br /> -- (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> .. � �• <br /> APPLICATION ACCEPTED BY � �� ;�ir�r[ 'f/' !"r�' DATE ' ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION- PHAVIIIJINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6-Iox <br /> EH 1426 Rev 12-77~- - /7 8 -2M <br />