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SAN JOAQUIN LOCAL HEALTH UISTRICI <br /> OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No. �6 <br /> C Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,s Z-_7 <br /> [ <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 fora permit to construct <br /> and/or install the work herein described'. This application is .made in compliance with _San , <br /> ,'oaqui,n County Ordinance�No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 9istrict. f <br /> EXACTSTREET ADDRESS lv H / CI-TY/TOWN <br /> Owned s Name Phone' 9-J/- Z,22 7 <br /> Address <br /> City <br /> Contractor's Name Licensef,,;�2agor .Phone Vy. Z 2 <br /> ?S CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURA"•SCE ON FILE WITH SJLHD? -'YES NO <br /> TYPE OF WORK (Check) : UW WELLd DEEPEN ❑ RECONDITION DESTRUCTION❑ I <br /> WEL L RINATION 0 WELL ABANDONMENT OTHER ❑ <br /> PUMP INSTALLATION: LJ PUMP REPAIR❑ UMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES Zjg2 PIT SAPRIVYA&i-�6THER04? <br /> SEWAGE DISPOLF.IELD- I CESSPOOL/SEEPkGE <br /> PROPERTY. LINEJd PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE j, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial wo- able Tool Dia. of Well Excavationp <br /> I Domestic/private "i Drilled Dia. of Well Casing '* <br /> iI Domestic/public Driven Gauge of Casing <br /> EI Irrigation Gravel Pack Depth of Grout Seal ,,'B <br /> d Cathodic Protection Rotary . Type of Grout <br /> 'il: Disposal Other- Other Information <br /> 11 Geophysical � ,.: Surface Seal Installed by:_ 9,4&52 <br /> PUMP hNSTALLATION: Contractor i 7 <br /> - Gd1CA, <br /> Type of Pump _, S"y�a. H.P. <br /> � <br /> PUMP REPLACEMENT: j State Work Done I <br /> PUMP REPAIR: ❑State Work Done - ._.._.:. <br /> DESTRUCTION OF WELL: Well Diameter��` Approximate Depth ZgQ <br /> # Describe Material and Procedure zqvdS"U <br /> � cr <br /> I hereby certify that I have prepared this application and that the work will be done in accordancf <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 /> "Ilcertify that in the performance of the work for which this permit is issued, I shall <br /> noit employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California." ' <br /> I WILLI, CALL WR Jk GROUT -INSPECTION P IOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNE6� ,4 <br /> it �(D�RAW <br /> TITLE: 7 DATE;r-/2 7,, <br /> OV <br /> !C �� F DEP RTMENT USE ONLY <br /> PHASE :ill <br /> APPLICATION ACCEPTED BY - DATE �, <br /> ADDITIONAL COMMENTS: <br /> 1 <br /> P II bROUT INSPEC -PHASEZIf FINAL INSPECTION <br /> INSPECTION BY DATE 2 INSPECTION"BY DATE 71 <br /> EH 2426. Rev. 12-77 1 /78 2M._.f <br />