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I SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> iiFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit N •`7 `�- �`� <br /> 14z— <br /> Telephone«- (2-09) 46676781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ( -� <br /> This Permit Ex fres-1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br />: l <br /> Gand/or install the work herein described., This application is made in compl-iance.with San <br /> c'oaQui n County Ordinance No. ,`1862. and --the Rules and Regulations of the -San -Joaquin Local Health <br /> District. c� # <br /> EXACT STREET ADDRESS ,19 CT.9 /Vny\1U CITY/TOWN__ a <br /> Owner's Name l Y E p � e nPhone s �� <br /> Address O. " � City -5T0 ar Al .. <br /> Contractor's Name N � oS, QR r���u License 91 Phone_ 3 6'. l57 <br /> I1S. CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE O4! FILE WITH SJLHD? YES NO- <br /> ! A 'O RECONDITION DESTRUCTION <br /> TYPE <br /> O,TYPE OF WORK (Check) : NEW WELL'S DEEPEN C� RECONDITION ❑ DESTRUCTION[] <br /> .,WELL CHLORINATION p WELL ABANDONMENT 0 OTHER <br /> I NSTALLAT-I ON LL[]—pUMP-REPAI R o'--'PUMP-REPL-ACEMENT_C1� <br /> r , 0 <br /> DISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD.. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTI-ON SPECIFICATIONS O ,f P <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> `--—Domes.-Oc%private Drilled= Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing CL <br /> Irrigation �� r / Gravel Pack Depth of Grout Seal <br /> Cathodic` Protec>" Rotary Type of Grout - <br /> i, Disposalb � Other Other Information <br /> Geophysical k. Surface Seal Instal-led-by: <br /> rt <br /> 'PUMP INSTALLATION:- -:., Contractor -el- °'t --^ - <br /> Type. of Pump H. <br /> �i,PUMP' <br /> . <br /> ,.PUMP' REPLACEMENT: - [3 State Work Done <br /> =IPUMP REPAIR: Q State Work Done <br /> � DESTRUCT.ION OF WELL: Well 'Diameter Approximate Depth <br /> a Describe Material and Procedure <br /> I hereby certify that I have prepa,r,.edthi.s.,application and that the work will be done in accordanc <br /> .with San Joaquin County Ordinances-;,State Laws , and Rules and Regulations of the San Joaquin Local <br /> lHealth District.` oHome owner or�-lifcensed'.agent' s signature certifies the following: <br /> "I certify that in the perfo.r_mance_of.�the work for which this permit is issued, I shall <br /> not employ ariy person in such manner as to become subject to Workman' s Compensation <br /> Taws of Cal'ifornia. " 11 <br /> ` I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:,4� <br /> PLT PLN ON REVERSE 4-J-4- <br /> ( IT- <br /> DRAWDE <br /> FO EPARTMENT USE ONLY <br /> PHASE I '' . , �. _ _ - �� . .� -. .- _.. _ t-: <br /> APPLICATION ACCEPTED BY DATE <br /> ; ADDITIONAL COMMENTS: f <br /> PHASE IFI3GROUT INSPECTION 'PHASE III FINAL INSPECTION <br /> INSPECTION BY y_ DATE - -- " `�` TNSPECTiON 'BY ( -DATE 0 <br /> ru 1aoc - o,.., i�_'r7 Y 1 /78__ 21K. <br />