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SAN JOAQUIN LOCAL HEALIM UlsIK1CI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. »/s2,ij, <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g"23? - <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 /> ,oanu1n County Ordinance No. 1862 and the- Rules and -Regulations of. the. San Joaquin Local Health <br /> Jistr�ct. <br /> EXACT STREET ADDRESS �3.�d �� Z ✓ CITY/TOWN` <br /> Owner's Name Z� V7 TA-to /`'] mo i] 1-7 Phone4 <br /> Address i �- Z' .L7 149--VILF- Ci ty-, O <br /> Contractor' s Name_ -� �—� f �S License#✓0/ �'ZT?3 Phoneme � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? ` YES NO <br /> TYPE OF WORK (Check) : NEW WELLa�' DEEPEN ❑ RECONDITION ❑ DESTRUCTION[) <br /> WELL' CHLORINATION ❑- WELL ABANDONMENT ❑ OTHER❑ W <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> Rs <br /> DISTANCE TO NEAREST: SEPTIC TANK' '--SEWER LINES �'�` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> lafi PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SP£CIFIC' TIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> --Z;� —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 b : ,B <br /> PUMP INSTALLATION: Contractor s-� TSU^4,p � <br /> Type of Pump i 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 an2 Procedure <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 o�- _-VVGROUt <br /> rnia <br /> I` WILL CAIN PECTION PRIOR TO GROUTING A FINAL INSPECTION. <br /> SIGNED T I T L DATE: // - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 11- 0-79 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION B� DATE Jl 1(�- 7f _..— INSPECTION BY DATE <br /> r <br /> EH 1426 Rev. 12-77 <br /> 1/78 2M <br />