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5f1N JUHC U 1'fV LUCAL HLAL 1 H UI5 1 RI L I <br /> OFFICE USE: 1601 E. ' Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 ; <br /> APPLICATION: FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -22- <br /> This Permit Ex fres 1 Year From Date Issued <br /> Compl ete. In Triplicate <br /> Application' is hereby made to the SanJoaquin Local Health' District for a permit •to construct <br /> and/or install the work hereintdescribed.' This application is made in-.compliance with San <br />�oaQuin County Ordinance No. 1862 and the Rules `and Regul-ations of the San .Joaquin -Local Health <br /> District. <br /> EXACT. STREET ADDRESS �` /19-vi -- CITY/TOWN - - <br /> :x t.� <br /> Owner' s Name Pfau L k, Phone s�-►e, <br /> Address C4 City.. �1 . <br /> Contractor's Name �� Licensee EI Phone 41,1w-flyO'3 57 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSA ION INSURANCE ON FILE WITH SJLHD? YES v NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> -� -- - WELL--CHL-ORI NATION--❑ _ WELL -ABANDONMENT 0- - -OTHER ❑ -_ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT E - � <br /> D I STANCE TO NEAREST: SEPTICJ;f - K S D{ 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 <br /> Industrial Cable Tool Dia. of�,Weli Excavation <br /> Domestic/private Drilled Dia. of--Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth. of' Grout Sea <br /> Cathodic Protection 'I Rotary Type of Grout <br /> >,. <br /> Disposal � Other --M&-Information -- <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump :. H.P. <br /> i <br /> PUMP REPLACEMENT: [I Stalte Work Done <br /> t <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an Proc-e ure <br /> I 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 Regulation`s, 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 /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws o California." <br /> f if rnia. <br /> " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> f <br /> (DRAW PLOT PL N ON REV-FRSE SIDTVE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE4Z <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY �_,/ DATE <br /> IN M99 Maki 19-77 _ 1/78 2M <br />