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SAN JOAQUIN�l;OGAL.�HE I,TH DIS-TRICT <br /> FFiCE U5E: 1601 E. Hazel <br /> ton Permit Stockton, CA 95205 Permit No.Zr_/d3?y- <br /> Tel eplione r 0209) 46,6-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued x-15 78- <br /> Thi's 'Permit,'Ex i resx 1 fear Frorri„Date ,I"sued ' f <br /> { Complete In -Trip ' cate <br /> Application is hereby made to the San Joaquin' Loca.1•.Nealith� Distr,i.ct� for .& permit,,to-.construct. <br /> and/or° instal 1 the`'work herein described..-; This .app.licattonf:is, made-in compl-iance with, San <br /> 2canuin Cov.nt5y,.G'rCari nce ��ya.{.1862Nand the. .R-ules =.and-.Regulattons of. the San,Joaquin,Lo al -H alth <br /> District. <br /> EXACT' STREET <br /> . ' DFD�RESSe. CITY-/TOWN <br /> N <br /> _:. <br /> Owner' s Name --- <br /> f <br /> Phone <br /> Address- .�ti °°L• <br /> <�F. <br /> Contractor's Name License# Phone.kl 2 <br /> IS CERTIFICATE OF- WORKMIAN"S' COMPENSATION INSURAM "-,QN FILE;WITH- SJL�D? -YES 140 ~- <br /> TYPE OF WORK (Check) : NEW WELLLX DEEPEN ID RECONDITION ® DESTRUCTION[ �_. <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION [ I PUMP REPAIR 0 PUMP REPLACEMENT �.. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIVES PIT PRIVY <br /> SEWAGE ;DISP SAL FIELD C�SPOQ�f /SEEP GE PIT ..rte OTHER PROPERTY , LIN&40RIVAT OMESTIC .WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.- of Well Excavation 12 <br /> Domestic/private A Drilled-1 Dia. of Well Casing <br /> Domestic/public Driven - Gauge of' Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection � y Rotary Type of Grout <br /> Disposal Other Other Informationi <br /> Geophysical Surface Seal. Insta l'T ed b : <br /> PUMP.. INSTALLATION: Contractor - <br /> Type of�Pump H. . <br /> PUMP REPLACEMENT: ❑State Work Done + <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe-Materia and- Procedure <br /> I hereby certify that I have prepared this application dnd 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 Cal'ifornia." <br /> I WILL C FOR G. UT ECTION PRIOR,TO' GROUTI;NG AND A. FINAL INSPECTION. <br /> SIGNED `_TITLE: DATE: <br /> i DRAW PLOT PL N ON REVERSCISIDET ` .t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A�� <br /> APPLICATION ACCEPTED BY DATE <br /> ADOITIONAL. COMMENTS: i07 <br /> PHASE" II: GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY hDATE 4'_—,INSPECTION BY. DATE 5' <br /> 44 1 d9A" 'Pnxi ' 19_77' w _ .m.._ _.. m 1 /78 — 2M <br />