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SAN JUAQUIN- LOCAL .HtAL I H UIS I KIU I <br /> EFOR FFICE USE: 1601 E. Hazelton Ave. ,: Stockton, CA 95205 Permit Na. <br /> Telephone (209) 466-6781 <br /> APPLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _93y <br /> This .Permi.t Expires 'I- 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 Ordinan e o. 18 2 and. the Rules and Regulations o-1 t San .Joaq in Local Health � <br /> District. �/1,�, -e,��� Y� � � � '� 9 �r <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone_ fp`b- _1;-V <br /> a <br /> Address City <br /> Contractor's Name License# Phone 670 <br /> ,SCERTIFICATE 4F­WORKMAN'S C0"iPENSATIT11- INSURA"JCE ON FILE WITH -_SJtHD?-­­YES­-7L <br /> TYPE OF WORK (Check) : NEW WELL K DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ - <br /> PUMP .IN'STALLATION,$3- PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK A n r SEWER LINES PIT PRIVY <br /> SEWAGE DI-SPOSAL FIELD CESSPOOL/SEEPAGE PITA0,Ae_0THER <br /> PROPERTY LINE .-: PRIVATE DOMESTIC WELL -.,•PUBLIC DOMESTIC WELL, <br /> INTENDED USE —' TYPE OF WELL w _ CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. -of Well Casing <br /> Domestic/public Driven Gauge `of Casing <br /> Irrigation Gravel Pack Depth of .Grout_.S.ea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal- Ihstal--ed b <br /> r <br /> PUMP INSTALLATION: Contractor --t <br /> Type of Pump , HT <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL' ,, Well Diameter. Approximate -Depth - <br /> _: <br /> Descri.be.. Mate,rial and Procedure <br />. I hereby certify that I'have prepared this application and that- the work will be done in accordant <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 signature certifies the following:,'" <br /> "I cervi fy.-:.that in the performance. of the work for which this permit is issued, I shall <br /> not employ any person in-su'ch manner as to ,become, subject to Workman's Compensation <br /> `laws of California. " <br />�`,Is`WILL CALL FOR A GROUT INSPECTION 'OkIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: l <br /> (DRAWP OT —PL——N ON REVERS SIDE <br /> FOR EPARTMEXT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �ZDAT£ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION/ - ---- PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE = _ <br /> CU 1n11e D, 11) -77 `�' 1 /78 2M . <br />