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SAN JOAQUIN;LOCAL .HEALTH DISTRICT <br /> -. FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ' <br /> Telephone: X209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g,,,14-2e <br /> This Permit Ex ires 1 Year From Date Issued.. . <br /> (Complete.in Triplicate , <br /> ppjj � <br /> Application is hereby made to the San Joaquin Local Health Districtlfo ��4 rmit 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 DCRESS. , (P DLtr l 19CITY%TOWN <br /> Owner's Name Phone_?� .. �, 5C9 <br /> Address M:. - City.. <br /> Contractor' s Name2 ' <br /> License# 4, � Phone � ' ��3� <br /> IS CERTIFICATE OF wnr 1f1ArV S COMPENSATIO,! I ISURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF 4JOR1C`(Check) NEW'WEELLD-"—DEEPEN p-• -RECONDITION Q DESTRUC-T-TON-Ej r <br /> WELL CHLORINATION D WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION 5a PUMP REPAIR EJ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-,-PIT OTHER �t 4 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE J TYPE OF WELL `jCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool D a,"of We11 Excavation <br /> Domestic/private E Drilled -Dia, of Well Casing <br />—Domestic-/public Driven ; �" Gauge of Casing _ <br /> I.rrigation Gravel Pack~ ` Depth of Grout Sea <br /> Cathodic. Protection Rotary ' Type of Grout <br /> Disposal J f'- Y i Other,� r' Other Information <br /> Geophysical / Surface Seal Installed b <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP--RE-PL-ACEMENTt [].State Work Done r <br /> PUMP: REPAIR: Q State Work Done <br /> DESTR � � } <br /> UCTION OF WELL. WelJJQiameter_ Approximate Depth <br /> Des'6rfSe­Material and Procedure <br />[ hereby certify that I have prepared this application and that the work wi.11 be done in accordance <br /> vith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locals <br /> lealth 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 k <br /> laws of California. " <br /> WILL CALL EWA qR10UT INSP CTION PRIG 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> f nn AW PL T PL N ON REVERSE IDE <br /> OR DE ARTM NT USE ONLY <br />'HASE I R <br />,PPLICATION ACCEPTED BY !:+ DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION <br /> HASE III F AL -INSPECTION + <br /> NSPECTION BY DATE /� INSPECTION BY- DATfF./Q�,�► W , <br /> H 1426 -Rau 19-77 <br />