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FOR .9`-F'CE USE: 1601 F 'lazel ton Ave. , Stockton, CA 9` 5 Permi t No. <br /> (elephone: (209) 466-6781 <br />— ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-z-,/-7.F <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 u <br />'oaouin County Ordinance 1,o . 1862 and the Rules and Regulations of the San Joaquin Local Health IQ <br /> District. <br /> EXACT STREET ADDRESS p ' Q 1J CITY/TOWN <br /> Owner' s Name 40p ?0. ZoK 1061 Phone <br /> Address 5-9i-k EW- 5QMW / -0E— City <br /> Contractor' s Name CLPtkK DELL c Et,�,IIIPtijail License# Z Phone /'• 3 <br /> IS CERTIFICATE OF WORKtIAN'S COMPENSATION IINSURANCE ON FILE WITH SJLHD? YES l/ NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR ❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKZ f-6 ' SEWER LINES PIT PRIVY <br /> f;,41 <br /> ,/ z SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Ir k y'27' PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTE ED USE TYPE ELL CONSTRUCTION SPECIFICATIONS <br /> ustrial able Tool Dia. of Well Excavation 14#1 <br /> Domestic/private Drilled Dia. of Well Casing /o" <br /> Domestic/public Driven Gauge of Casing 1k r <br /> Irrigation Gravel Pack Depth of Grout Seal S-o <br /> Cathodic Protection Rotary Type of Grout_ (1, f A(� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 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 Cali rnia. " <br /> I WILL FOR A GROUT INSPE ON PRIPR n GROUTING ANDA FINAL INSPECTION. - <br /> SIGNED TITLE: wA)E g DATE: 4 271 <br /> D W PLOT LAN ON REVERSE SIDE <br /> FUR- DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY CY, DATE 6 7 <br /> ADDITIONAL COMMENTS : O/ i fro i.=e,l or 4 i/ el <br /> PHASE II GROUT I SPECTI N PHASE r1I FINAL INSPECTION <br /> INSPECTIJN BY CIX DATE / INSPECTION BY DATE 6 <br /> IEH 1426 Rev. 12-77 ` 1 / 7 2M <br />