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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Aug:., Stockton, CA 95205 Permit No. <br /> 7g, Telephone:- {209} 466-6781 Date Issued/0�3/-2Z ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permi.t. Ex fres 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 incompliance with San <br /> oanuin County Ordinance No. 1862 and the Rules .-and-.,,Regulations of,the San Joaquin Lacal.. Health <br /> CiStr�Ct. � , <br /> EXACT STREET ADDRESS aZ. 7 /• fGrrd d✓ CITY/TOWN ,Lr <br /> Owner' s Name A11r, /�91ille 25 —11r/v,14,v ,- `i ore i�u /���s —P a SSG (� - 4 7 <br /> Address .A�-y4 / /m W" a,r d d <br /> �._ _ ��Qo. r � City <br /> �o <br /> Contractor' s Name .4ta�,.Cvv,'� �1?c-l/% License736,ie Phone 16 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURMICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL,D- DEEPEN El` f RECONDITION-[:)'-- DESTRUCT.IQN <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 �, <br /> PUMP INSTALLATION R. PUMP REPAIR❑ PUMP REPLACEMENT C] f <br /> DISTANCE TO NEAREST: SEPTIC jTANK Lad Vit- SEWER LINES 7S —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 S _ Cable Tool Dia. of Well Excavation <br /> <Domestic/private i Drilled Dia. of Well Casing_ k _ E <br /> Domestic/public I Driven - Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout ,tl __�`- <br /> Disposal i Other Other Information <br /> Geophysical ,. �, Surface Seal Installed b : ,L <br /> PUMP INSTALLATION:- Contractor - l-4-a-y [Z''4bCL �L - -r LL I v.c _. � ��,, <br /> Type of; Pump ,2 d r g., H.P. J,,/P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ~ - =Approximate -Depth <br /> Describe Material and Proce ure <br /> I <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 shal l <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 INSPECTION PRIOR TO GROUTING AND A, FINAL INSPECTION. <br /> SIGNED TITLE: DATE: /d— s©•-72 <br /> DRAW PLOT PL N ON REVERSE SIDEY <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 0 3/ 7 OCI" <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE//` 310 <br /> CU In�G o,,., 10_717 1/78 2M. J <br />