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_ SAN JUAQU1N LUCAL HEALTH UiJIKIUI <br /> FFICE USE: " 601 E. Hazelton.Ave. , Stockton, CA 95205 Permit No. _) g0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> l43- <br /> Aoplication is hereby made to the San Joaquin Local Health District for .a permit to construct <br /> acid/or install . the work herein described. This application is made in compliance with San <br /> ,oaquin County' Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. � n�"" <br /> EXACT STREET ADDRESS CITY/TOWN F9ZXCW CApo. <br /> Owner's Name ��.s. [�19�D�s . . ..__, <br /> Phone <br /> Address 0-.4 City <br /> Contractor' s Name 00-cenu0 j License#2MZOAPhone 466=0- <br /> TS CERTIFICATE OF WORKMAN'S COIMPENSATIO1111 INSURANCE ON FILE WITH SJLHD? YES NO � <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 'f9 OTHER FJ- <br /> PUMP <br /> PUMP INSTALLATION ❑ 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 RUB61G, DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C7 <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 Seal <br /> Cathodic Protection Rotary , Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth X50 <br /> Describe Mate'rial and ProcedureC.�ger21_ <br /> 1 hereby certify that I have prepared this application 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 signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> no employ any person in such manner as to become subject to Workman' s Compensation <br /> 1 ws of Ca fornia." <br /> I WILL C& L FW A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: muDATE: 10 Zahg <br /> (DR-TW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOg D TMENT USE ONLY <br /> APPLICATION ACCEPTED BY a DATf�/' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,41NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B _ --4 DATE Z&)2-2gL- <br /> EH 1426 ._Re.y. 12-77 n 1178 2M <br />