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SAN JOAQUIN -LOCAL HEALTH DISIRICI <br /> EQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ` <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued& <br /> Z <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 <br /> Joaquin County .Ordinance No. 1862. and ,the ,Rules and Regulations of the San Joaquin .Local Health ! <br /> District. <br /> EXACT STREET ADDRESS *_- _)40 W4 R 1) CITY/TOWNCZ2C�(� <br /> Owner's Name_ and s - apl wE b r i :CA3 - Phone_ll(pt 6,06 / ;[ <br /> _ <br /> Address .-I ! 4,Q A/, EL i12A/Do � � City .G/G Q - J <br /> Contractor' s Name GL4R b . V)i �S//P CDS Licensed (, Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE_-ON _FILE WITH 'SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN C1 RECONDITION Q DESTRUCTION d I <br /> ' WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0- <br /> PUMP INSTALLATION CI PUMP REPAIR p . PUMP REPLACEMENT—Q <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 Jool Dia ' of Well Excavation O F <br /> �Oomestic/private Drilled Dia. of Well Casing &3- <br /> Domestic/public Uri ven' 17 ~,Gauge .of Casing 4714 S s /Gcff <br /> Irrigation too- -a Vol Pack .,{ Depth of-Grout Seal <br /> Cathodic Protection Rotary ,,,Type of Grout 19#k AAA :i A� I <br /> Disposal Other Other Information <br /> Geophysical ; o Surface Seal Installed by: <br /> ` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4 <br /> PUMP REPLACEMENT: Q State Work Done 4 <br /> PUMP REPAIR: ❑State Work Dane I <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Materia an roteu-F <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State -Laws ,tand 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' WDrkman's Compensation s <br /> laws of California." <br /> I WILL CALL FOR A WUT INSPECTION PRIOR -TO GROUTING AND A FINAL INSPECTION. E <br /> t SIGNED �.'i TITLE: -&4PerJ1St1rc,4 DATE: 0A'Z- <br /> �DR W. PLOT PLAN ON,REVERSE SIDE <br /> OR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED 8 ' DATE2-,,4v-79_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY y "" DATE INSPECTION BY DATE y-i3-�� <br /> EH 1426 Rev. 12-7.7 ._ 1/78 2MI <br />