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SAN JOAQUIN LOCAL kNEALTH DISTRICT Permit Na. 79--- 115-- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued_,5,j22_1_79 ._ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Triplicate) <br /> Aoplication is hereby made to 'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN Phone fo a <br /> Owner' s Name � • . <br /> 1 & City 001 <br /> Address- <br /> Con trac 6..e Name Li cense# Phone_ IAJ _ <br /> r <br /> IS CERTIFICATC OF WORK"IAN'S C0`1PEINSATIO'J I'NSURA'NCE ON FILE WITH SJLHD? AYES NO y' <br /> - TION <br /> TYPE OF WO'RfC (Check) : NEW WELL CI DEEPEN ❑ REtONDI ❑ ESTRUCTIQ <br /> WELL C7MINATION ❑ WELL ABANDONMENT 0 THER,fti l 0-' <br /> PUMP INSTALLATI.O.N-D—P_UMP..,REPAIR❑ PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER•LINES$z?:- PIT PRIVYitJ-P� <br /> SEWAGE DISP_ SAL FIELQ CESSRQ'OL/SEEPAGE IT yac� OTHER �d�— <br /> PROPERTY LINE%�'ARIVATE DOMESTIC WELL 14igL-L- PUB LTC DOMESTIC WELL <br /> ' CONSTRUCTION SPECIFICATIONS r <br /> INTENDED USE'S# `. TYPE OF WELL4 <br /> Industrie, =' :� �Catil_e Taal Dia. of Well Excavation <br /> Domestic/priva.te-^ *%�_7_Drilled Dia. of Well Casing <br /> Dornsti c/public ` Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection- Rotary Type of Grout <br /> Disposal . Other_ _ Other Information -- <br /> Geophysical Surface Seal Installed b .�- <br /> PUMP" I-NSTALLATION: Contractor H.P. <br /> Type of Pump <br /> 'PUMP, REPLACEMENT: State Work Done <br /> PUMP -REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: We11 .Diameter /l Approq mate Depth Q <br /> ---� Describe Materia ,, rocedure <br /> I hereby certify that I have' prepar this application and that the work will be done in accordant <br /> , and Rules and Regulations of the San Joaquin Local <br /> withSanJoaqu,in .County. Ordinances , State Laws <br /> Health District. ?dome 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 . " <br /> G AND A FINAL INSPECTION. <br /> I WILL -CALL FOR GROAT - NSP ION PRIOR TO GROUTIN <br /> D. •z: <br /> ' TITLE: 67 <br /> DATE: <br /> SIGNED w <br /> � PLOT PL N ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I DATE Z <br /> k APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS : PHASE III INAL INSPECTION <br /> PHASE I GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ���c� 5 7 9 i`1 <br />