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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7;'-/1 ,9'y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �S 7 <br /> This Permit Expires I 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 /> Pp <br /> and/or .install the work herein described. -This application is made in compliance withNSan <br /> Joaquin County 0rd:inance No, 1862 and the Rules and Regulations of the San Joaquin Local"Health <br /> District. <br /> EXACT STREET ADDRESS ZO C- CITY/TOWN Fi2eiu&,�-M #4 <br /> Owner's Name Phone 96 2- - L <br /> Address 23 Vj . 4CA `t- KQJj _ C 1410 City <br /> Contractor's Name GL/Q�(21Ci Z,(, License# 76 42 Phone 4&?_�6 <br /> IS CERTIFICATE OF WORKMAN'S CO111PENSATIOIN INSURANCE-ON FILE WITH SJLHD? YES � _ NO <br /> TYPE OF WORK (Check) : NEW WELL V( DEEPEN Q RECONDITION ® , DESTRUCTION d w <br /> WELL CHLORINATION Q WELL ABANDONMENT-0,, ­OTHER 0 <br /> " PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT Ca <br /> 0 <br /> DISTANCE TO NEAREST: '` ,SEPTIC TANK r6 D - SEWER LINES 100 `PIT PRIVY 3 R <br /> 'SEWAGE DISPOSAL FIELD /4X) CESSPOOL/SEEPAGE PIT/� .�OTHE <br /> PROPERTY LINE -, PRIVATE DOMESTIC WEEC PUBLIC DOMESTIC WT'L <br /> INTENDED USE TYPE OF WELL 4CON.STRUCTION SPECIFICATIONS <br /> Industri•a1 Cable Tool Dia. of Well Excavation r4 <br /> j)omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Sea -J!r <br /> i Cathodic Protection t v--IGotary Type of Grout, <br /> Disposal ! Other Other Information <br /> Geophysical Surface Sealf Installed by: <br /> t PUMP INSTALLATION: Contractor- <br /> TYPelof Pump H.P. , <br /> f PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: O St to Work Done <br /> DESTRUCTION OF WELL,`. Well ' Diameter Approximate Depth. <br /> Desc H be Material and Procedure <br /> k <br /> I hereby certify that I ,have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws; and Rules and Regulations of the San Joaquin Loca <br /> Health District. Home owner or licensed agent' s signature certifites�,the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> k not employ any person in such manner as to become subject _to-Workman's Compensation <br /> laws of California." <br /> I WILL CALFOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED o �, - TITLE: DATE: <br /> DR W-PL Tr-PL N ON -REVERSE. SIDE <br /> FOR DEplwqm <br /> ENT USE ONLY <br /> 4. PHASE Ito DATE <br /> APPLICATION ACCEPTED BY <br /> h ADDITIONAL COMMENTS: OC <br /> PHA E I I GROUTL .INSPECTION `' x PHASE III, FINAL INSPECTION <br /> INSPECTION BY I DATE P-3 - �8' _ INSPECTION BYgf�iAN4e-- DATECU <br /> c <br /> l AqC 10_77 117 `" 2M <br />