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j SAN JOAQUIN. LOCAL HEALTH UlSr� 10 ' <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit �l Now _ <br /> Telephone: (209) 4616-6781 <br /> Date Issued <br /> APPLICATION FOR WELL.-CONSTRUCTION OR PUMP PERMIT <br /> r This Permit Expires '1 Year From Date Issued <br /> Complete In Triplicate M <br /> i <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 appl,.ication is made in compliance with San <br /> ,,oaquin County, erdinance No. 1862 and the Rules.and Regulations ,of the San Joaquin. Local Health � <br /> District. /;Z!5/ P--Z>W of VVAAG <br /> EXACT STREET ADDRESS � O� �p[�[a��-- ��. !at� T11Y/TOWN pe <br />€ Owner's Name ,e- .5 f 4 Phone --796 Z <br /> Address.. ¢A 5 Ci tyc/ <br /> Contractor's Name 61aSpAl L� UW,4 License#337,0 Phone 7 337 :z <br /> i IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 1,40 <br /> I TYP-E--O,F-WORKS-(Check): NEW W,ELL,N DEEPEN ❑ = 'RECONDITION C3 D&STRUCT,IONQ r <br />' W€LLI-�CHL--OR-I-NAT-I-ON-Q.-WE LL-A BANDONMENT_1C�] =OTH-E-R-fes <br /> ---Pump-i- TALL-ATI-ON� -� UMP- -PA-I-R-B----.PUMP• -REPLACEMENT-.g -,.� -- n <br />' DISTANCE TO NEAREST: SEPTIC TANK 300 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 3� CESSPOOL/SEEP PIT OTHER <br />� - PROPERTY LINE PRIVATE: DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We 11 Excavation .r I,esT- <br /> _Domestic/private Drilled Dia. of Well Casing _ S <br /> Domestic,%public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodi ' <br /> Protection Rotary Type of Grout <br /> I, Disposal Other Other Information <br /> Geophysical 'A rf a Seal Installed by: <br /> # S 'dzJ # <br /> PUMP INSTALLATION: Contractor W -D57 <br /> dZ <br /> Type of Pum If .tr�,�s �� H.P. <br /> . <br /> PUMP REPLACEMENT: [l State Work � <br />; PUMP REPAIR: ❑State Work Done ` f <br />` DESTRUCTION OF WELL: ._ Well Diameter Y <br /> pproximate De.ptt _Describe <br /> Materia and: Proce ure <br /> I hereby certify that I have prepared this a`p'plication 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 �5ig6Ytur`e certifies the following: k <br /> I certify that in the performance of the work for„which this permit is ' issued, I shall "!! i <br /> not employ any person in such manner as to become 'subject to Workman's Compensation <br /> laws of California, ” i <br /> I WILL CALL FDR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. �I <br /> SIGNED TITLE: DATE: la- 7 ' <br /> DR W PLOT PLN ON REVERSE SIDE. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL COMMENTS: + f <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE <br /> INSPECTION BY m DATE <br /> '/1. <br /> H 1426 Rev: ]:2-77 _ 1178 <br /> F . _ , <br />