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SAN JOAQUIN` Lg%AL�I11'EALTH DISTRICT <br /> EQR OFFICE USE: 1601 E. Hazel to <br /> n- Ave: ' Stockton, CA 95205 Permit No.7s����7� <br /> Telephone: (209) 456=6781 Date Issued r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT } <br /> This Permit Ex ires l Year From Date -Issued <br /> Complete In Triplicate <br /> Application is hereby made to j . <br /> JoaquTh7soaa'licationealth Distmade inrict, f rcomp1.iance. a permit twith nSan <br /> uct <br /> and/or install the work• hereindescribed. pp <br /> Joaquin County Ordinance No.. 1862 and the:. Rules 'and Regul ati ons of the �3J o qui nLocal Health <br /> Diistrict. f0Q52 S` <br /> CITY/TOWNS er <br /> EXACT 'STREET ADDRESS -&4c �ti� aOf°�, ��� Phone <br /> Owner's. Name �U City C <br /> AddressL L ZZ <br /> License# C Phone f 3 <br /> Contractor' s Name r ; <br /> IS CERTIFICATE OF WORKT1Ai1'S COP•1PENSATION ITISURA"!CE OTI FILE WITH SJLHD? YES <br /> LL DEEPEN <br />'. TYPE OF' WORK (Check) : NEW WE ❑ RECONDITION C3 DESTRUCTION[], <br /> i <br /> - WELL tHLORINATI.ON'[D WELL PUMP ABANDONMENT <br /> ❑ NT 0 MP OTHERREPLAMEN i` C� + <br /> PUMP INSTALLATION <br /> I DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES PIT PRIVY <br /> SEWAGE; DISPOSAL FIELD t CESSPOOL/SEEPAGE PIT v� <br /> PROPERTY LINE'39,FPRIVAT DOMESTIC WELL PUBLIC DOMESTIC WELL. N N <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well-Excavation <br /> 4 Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Sea <br /> t/rrrigation Type of Grout <br /> ' Cathodic Protection Rotary Yp - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> f INSTALLATION: Contractor ry L <br /> ' PUMP INST H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: Q State Work Done "" <br /> . PUMP REPAIR: ❑State Work Hone <br /> :! Approx`mate Depth <br /> DESTRUCTION OF WELL: Well Diameter . <br /> Describe Materia andthe Proce ure <br /> rdanc <br /> I hereby certify that I have prepared thisLapplication and <br /> es andaRegu1at�onsrk 'woflthe SaneJoaquinoLocal <br /> kwith San Joaquin County Ordinances , Statws , and <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 /> such manner as to become subject to Workman' s Compensation <br /> not employ any person id <br /> laws of California." . <br /> , I WILL CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE <br /> SIGNED DR W PLOT PL N ON REVERSE SIDE <br /> ` FOR EP TMENT T ONLY <br /> PHASE I � DATE <br /> A fr- <br /> -'.T-P-PLICATION ACCEPTED BY <br /> [ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> 4 PHASE II ROUTiINSPECTION DATE, <br /> ' INSPECTION BY N ' DATA INSPECTION BY <br /> 1/78 2M <br />