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Y SAN JOAQUI,N LUCAL HEAL I H DISI RIC I <br /> gE!0R_'0F,F10E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3117 7 <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 for a permit to construct <br /> and/or install the work herein described. This application is made in compliance,with San <br /> ,'oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> District. <br /> EXACT STREET ADDRESS t... Q C1 CITY/TOWN ,-o4/i <br /> Owner's Name oLd A-0sc A. Phoner3 — Q z. <br /> Address dACACIA city o �� <br /> Contractor's Name eA-Pe z I Dre e License#yffPhone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION It4S1JRAMrF ON FILE WITH SJLHD? YESy NO <br /> TYPE OF WORK (Check) : NEW WELL 59' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ p� <br /> DISTANCE TO NEAREST: SEPTIC TANK-ft' SEWER LINESgfV, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT — OTHER -r <br /> PROPERTY LINE.c3`PRIVATE DOMESTIC WELL_5C� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial £able Tool Dia. of Well Excavation l 2-11 ^- <br /> Domestic/private Drilled Dia. of Well Casing l a y � t <br /> s 1c Tic Driven Gauge of CasingnE <br /> ms's <br /> Irri ation Gravel Pack Depth of Grout Sea�� <br /> a _ Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface- Seal Installed by:Jyr„(i��ral �la..•.� <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 <br /> Describe Material and Proce 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 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 /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE• e,.ka DATE: z /' <br /> DR W PLOT PL N ON REVERSE SIDE <br /> PHASE I FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />, H 1426 Rev. 12-77 " lG`"`- 1/78 2M <br />