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► SAN JOAQUIN ,LOCAL•HEALTH DISTRICT <br /> r FFICE USE: 1601 E. Hazel ton, Ave., Stockton, CA 95205 Permit No- 7q - <br /> Telephone: (209) 466..-.6781 <br /> APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Date Issued -;-� <br /> ` <br /> ThisPermi`t'Ex fires 1 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 /> .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 ADDRESS 4099 ,South Kaiser Road CITY/TOWN Stockton <br /> El in`'Yturri Phone '948-041.6 c <br /> k Owner's Name 3 <br /> Address 4099 South Kaiser Road City Stockton <br /> Contractor's Name Stowell Equipment Co. License# Phone 462-7676 <br /> IS CERTIFICATE OF WORKMAN'S iCOMPENSATION INSURANCE ON FILE WITH SJLHD? YES xxxNO s� <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ 'RECONDITION ® DESTRUCTION[2 <br /> WELL CHLORINATION (:3 WELL ABANDONMENT 0 OTHER 0 . � <br /> PUMP +INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 13 <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . Dia. of Well Excavation <br /> Domestic/private Drilled k Dia. of Well Casing <br /> Domestic/public Driven -r-Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary ;: Type of Grout <br /> Disposal Other LL. Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor cS�a mom/ H. <br /> Type of Pump r ti_, <br /> P. <br /> r <br /> i PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP, Rf#A44t--Lt„ CEState Work Done x-, -- AlotJ Ad. <br /> DESTRUCTION OF WELL: - WelliDiameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> '- I hereby certify that I have prepared this application., and:nthat 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 certifies the following: <br /> k "I certify that in the performance of the work for'which this permit is issued, I shall <br /> neLLFOR <br /> y p rso 'n such manner as to become subject to Workman's Compensation <br /> 1 for �a " <br /> I WA G P CTIO PRIOR TO GROUTING AND A FINAL INSPECTION.- <br /> SIGNTITLE: DATE: 13 }� tC <br /> (-DRAW PL' P N ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY` <br /> PHASE <br /> APPLICATION ACCEPTED BY Ile QATF - <br /> ADDITI170— <br /> ONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE inVFiNAL INSPECTIPN <br /> INSPECTION BY DATE INSPECTION BY DATA <br /> FH 142f Rpv- ..12-77- 1 /78 2M <br />