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V <br /> SAN JOAQU,IN ,LOCAL HEALTH DISTRICT <br /> OFFICE`7U E: 1601 E, Hazelton. Ave. , Stockton, CA 95205 Permit fro. ( <br /> Telephone: (209) 466=6781 Date Issued'//"71/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This' Permit Expires 1 Year From Date Issued <br /> . Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to: construct <br /> and/or 'install the work herein described: Thisapplication- is made in compliance with San �-� <br /> Pe Joaquin County Ordinance -No.! 1862 and e Rules and Regulations of the San Joaquin. Local Health <br /> .District. y7- y� S� /�/ <br /> EXACT STREET ADDRESS w / ITY/TOWN <br /> Owner's NameA-5vvv6o Phone rC7 dqj <br /> Address City ��� C Li <br /> Contractor' s Nam v License# Phone - 0 <br /> � ' .,M. ' r rt. <br /> IS CERTIFICATE OF WORKMAN'S C0��1PENSATIO�IjtJSURA�ICE_ Odd FILE WITHSJLHD. YES ,�0 <br />- TYPE OF WORK (Check) : NEW WELL K DEEPEN Q RECONDITION ® DESTRUCTION C2 (' <br /> WELL'�CHLORINATION -0— WELL ABA-NDONMENT-L�—OTHER-0— <br /> PUMP INSTALLATION PUMP,REPAIR 0 PUMP REPLACEMENT ED <br /> DISTANCE TO NEAREST: SEPTIC- TANK� SEWER LINES _ PIT-P_R_ VY E Y <br /> SEWAGE DISPOSAL FIELD uari_ E SPOOLjS { PAU PT-T OTHER,, =*F <br /> PROPERTY LINE -. PR'IVATEVMESTIC WELL '-PUBLICDOME ST Z- WELL <br /> INTENDED USE TYP,ESOF_ WELL CONSTRUCT ION1,SP-ECIFICAT IONS - _ <br /> Industrial Cable- Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of We W Casings <br /> Domestic/public Driven ,' Gauge of Casing_ <br /> Irrigation ?Rotary, <br /> ravel, Pack Depth of Grout,Seai -� i tsr <br /> Cathodic Protection Type of Grout `•h <br /> Disposal 0therr Other Information <br /> Geophysical Surface Seal Inst�a'll-ed. by. <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump-- <br /> PUMP <br /> ump PUMP REPLACEMENT: ❑ State Work Done J `i.. <br /> PUMP REPAIR: QState Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter _—App-r-oxamate 'Depth <br /> Describe Material and Procecfure <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;: 1. <br /> "I certify that in the performance of the work for which this permit is issued,', Iishall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE: s� DATE:S— .�� <br /> 42- AW PL PLN ON REVERSE SIDE <br /> FOR DEPARTMENT. SE ONLY— - <br /> PHASE I -- w <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : _ <br /> PHASE II 5ROUT I SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -- - INSPECTION BY DAT <br />-.EH 1422; 'Rav 19_77 1/78 2M <br />