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SAN JOAQUIN .LOCAL- .HEALTH DISTRICT <br />_ <br /> FOR OFFICE USE: ,0 1601 E. Hazelton Ave. , Stockton, CR 95205 Permit No. <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit. Ex fres 1 Year .From Date .Issued <br /> Compl ete -T-n,Tri pl i cate ; <br /> AppTication, is hereby made toy he San Joaquin Local HealthDistrict for a permit °to construct <br /> and/or install the work herein described.' This application is made incompliance with- San <br /> Joanu,n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health i <br /> District. <br /> EXACT STREET ADDRESS fVS' , e.fi'uS1 �CoAn/ CITY/TOWN Tam } <br /> Owner's Name o Phone 9a(3 <br /> Address CityT�j7`aw <br /> Contractor' s Name��' �,�� ,C+-,�G�,,� �� „� ,, - ��• C License Phonejy <br /> IS CERTIFICATE OF WOM1AN'S COMPENSATI011 I"NSURA"NCE ON FILE WITH SJLHD? YES i--- NO <br /> TYPE OF WORKf ({Check) : )�NEW WELL L DEEPEN 0 RECONDITION . ] DESTRUCTION EjA <br /> s WELL CHLORINATION [j, WELL ABANDONMENT p OTHER 0 ca <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP"REPLACEMENT - � <br /> DISTANCE TO NEAREST: SEPTIC TANK.,,��) SEWER LINES PIT, PRIVY <br /> ` SEWAGE DISP SO AL FIELD CESSPOOL/SEtPAGE PIT OTHER <br /> PROPERT,Y .LINE-._-. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE S , � 'TYPE-' OF WELL :CONSTRUCTION SPECIFICATIONS <br /> - <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of -W611 Casing <br /> Domestic/public Driven Gauge of: Casing <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection_ i Rotary . , Type of Grout <br /> Disposal, 41j Other' 4 ,' jO'the`r' Irifor^mation <br /> Geophysical ,, . i `� Surface Seal Instal ed by: <br /> PUMP INSTALLATTON: 1 Contractor ,� f A- <br /> C <br /> Type of-Pump H.P. <br /> PUMP- REPLACEMENT: ❑State Work Done - <br /> PUMP REPAIR: ❑State Work Done _ ' <br /> r <br /> DESTRUCTION OF WELL: Well-Dl�ameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 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." ri=' -� <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 7 <br /> a <br /> (DRAW PLOT PLTN ON REVERSE SIDE R <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP-PLICATION ACCEPTED BY i f s DATE ?l -- - - - - <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ) -XO ' <br /> FH I4?h Rau 19-77 �� l /7A 9M <br />