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f SAN JOAQUIN��LOCAL HEALTH DISTRICT <br /> .FFICE USE: (/ ISOI E. HazeltonfAve ' Stockton, CA 95205 Permit No.ze-/Mzd_ <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION R PUMP PERMIT Date Is ed <br /> ---- This .Permit Esc ices L.Yearr ate Complete -In -Triplicate ' <br /> Application is hereby made to the San Joaquin Local` Heal .,h i tr o e'rmit to construct <br /> aoac}Qrn County �'rir�anceee�18�2�andbed,' This applicat on `is "Al n compliance vrith San <br /> the Rules and Regul d o of the San Joaqu n,Local Health <br /> EXACT STREET; Ek0%ESS; 4 / I T <br /> Owner's Name Phone - $73:? <br /> Address ; Ci'iy= ,..,. . <br /> Contractor's Name AA A LicensefZfM.q Phone g <br /> jJ <br /> 47- <br /> IS CERTIFICATE OF WORK IAN'S COIiPENSATION Mel FILE, 11ITH SJLHD? YES I40 <br /> TYPE OF WORK (Check) : NEW WELtPQ DEEPEN 0 RECONDITIONS] DESTRUCTION Cl <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK&Olf SEWER LIMESPIT PRIVY <br /> SEWAGE DISPOSALFIELD �. C S�L/SEEPFGE PIT. OTHER -- .,ice„ <br /> PROPERTY LINVOLI PRIVA�MESTIC WELL Iaa PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5^ <br /> Industrial Cable Tool Dia, of Well Excavations 2 cb <br />=Domestic/private Drilled Dia. of .Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation �&ravel Pack Depth of Grout Seal + <br /> Cathodic Protection ±JeRotary Type of Grout . G <br /> Disposal Other Other Information �-- <br /> Geophysical Surface Seal.Installed b <br /> PUMP INSTALLATION: Contractor n� <br /> Type of PumH.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: OState 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 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. borne 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 td- become subject to Workman's Compensation <br /> laws of California." <br /> I WILL ML FORA QyR0UT0IUdPEgION PRIOR TO.GROUTING.AND A .FINAL .INSPECTION. } <br /> SIGNED TITLE: PATE: <br /> DRAW PLOT PLAN 0 EVE SID ✓ <br /> FOR DEPARWNTIJUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 8Y DATE G <br /> ADDITIONAL COMMENTS- <br /> PHASE: II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INS ECTION BY DATE <br /> EH 1426 Rev-. .12-77 <br /> 1/78 M_,-, <br />