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SAN JOAQUIN10CAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. -7 2- <br /> Telephone: A209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -1 -7 <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 per 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 /> nistrict. <br /> EXACT, STREET ADDRESS .7.. coo �a �, t,,, el' CITY/TOWN nyrtcy_ <br /> Owner's Name S'c CA � a Nlos eon., fc. Phone S34 - 6 2 <br /> Address s-,z7 Wrr. -_- City h <br /> Contractor' s Name gA r zz LAr cT2 t Li cense#/5X'o Q Phone J' /3 C t <br /> IS CERTIFICATE OF WORKMAN'S CO"4PENSATIO"; INSURAINCE ON FILE WITH SJLHD? YES NO <br />.'.TYPE Of WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONID <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ;!9- PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �C Domestic/private . Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor f, I <br /> Type of Pump XkA cr H.P. <br />` PUMP_. REPLACEMENT: El State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />[ I hereby certify .that I have prepared this application and that the work will be done in accordance <br /> iwith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> kHealth 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 <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPE BION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLEDATE: ?Z/,? '9 <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEZ/ <br />, ADDITIONAL COMMENTS: <br />" PHASE II GROUT INSPECTION PHASE_ II F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> GH 142A Pov ' 19-77 1/78 2M_.f <br />