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jSAN JOAQUIN LOCAL HEALTH DIS-IRICl <br /> FFICE USE: 1601 'K. Hazelton .Ave., ,- S'to°ckton, CA 95205 - Permit No. 2 5?-d2 5— <br /> telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued� � <br /> This Permit Expires l Year From Date Issued <br /> Complete,4 n Triplicate <br /> Application is hereby made to the San Joaquin Local Health­District for a permit- to construct <br /> anO/or install the work herein described. This application -is 'made -in compliance with San <br /> ,;oan�:in County Ordinance ado. 1862 and the Rules and Regulations of the .San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ` nA ci 12 92 SA RZCITY/TOWN',,-.&/--.-,, L_ <br /> Owner's Name J0 ,u t <br /> Pfione_��-� �S' 7 t� � <br /> Address <br /> Contractor's Name 'U.*/ 94 -v ,� LicenseU66 �� Phone 6c U!5!�T , <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES 4— NO <br />-TYPE-OP-WORK' (-Check) NEW `WELL 0--- -`-DEEPEN-0 - RECONDITION ❑ DESTRUCTION[]- <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 93-- PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 11 SEWER LINES /p7 ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS 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 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 sq <br /> Type of Pump u "79 <br /> Z H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> rf <br /> PUMP REPAIR: ❑State Work Done <br /> • 44., <br /> DESTRUCTION -OF°WELL: =--We.]I-Diameter Approximate-Depth:. <br /> j Describe Material- an Procedure <br /> 1 F <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 inthe 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." 11 <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: A& DATE:.- <br /> /- <br /> (DRAW AW PLOT PLTN ON REVERSE SIDE - J <br /> _ -FOR DEPARTMENT USE ONLY., <br /> PHASE I _ ;�.. <br /> APPLICATION-ACCEPTED BY f. n DATE // <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ",DATE <br /> 1426 Rev. 12-77 i /79, 2M # <br />