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SAN JOAQUIN LUGAL .HEALIh U1!) [K1(; [ { <br /> FOR FFICE USE.: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. 79- n. <br /> l `�._ <br /> Telephone: (209) 466-6781 <br /> r Date. Issued 3-a?-0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT E <br /> This Permit Ex ices .l Year From Date Issued- <br /> Complete In Triplicate <br /> App <br /> lication is hereb 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 /> 'loanuin County Ordinance No. 41862 and the Rules and Regulations of the San Joaquin. Local Health <br /> EXACT STREETADD SSCITY/TOWN f <br /> Phone__=fin <br /> Owner' s Name - - <br /> Address QA69, ��= l//', /� City <br /> Contractor' s--Named-- cense _ � _ Phone <br /> ......-- T L <br /> IS CERTIFICATE OF WOW'IAN'S COMPENSATIO"l INSURAINCE'ON FILE WITH, SJLHD?1--�­YES NO <br /> TYPE F WORK (Check) : NES' WELL j • " DEEPEN.❑ ~ RECONDITION DESTRUCTION 0 <br /> ,yam WELL;�CHLQRINATION 0 WELL ABANDONMENT p OTHER• <br /> PUMP fNSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT E) <br />' DISTANCE TO :NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY- _._.- _ p <br /> e SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER.. <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia. of Well-Excavation <br /> Do.mestic/private Drilled Dia. of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> QJ:sposal 40e Other Information <br /> Geophysical urface 5 Installed b : <br /> PUMP INSTALLATION: Contracto� Type of PuCl H.P. <br /> 1PUMP REPLACEMENT: E]State Work Done <br /> PUMP, REPAIR: []St to Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an .Procedure <br /> I <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: ' ' <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person i,n, such manner as to become subject to Workman' s Compensation <br /> laws- of, alifornia." 4 <br /> I WILL CAV fOR A GROAT INSPECT O - PRIO 10 _GROUTING ANDA F4NAL INSPECTION. <br /> SIGNEQ TITLE: DATEL n <br /> a* DRAW LOT PLN ON REVERSE IDE <br /> F R DEPARTMENT USE ONLY <br /> !PHASE IDATE <br /> rAPPLICATION ACCEPTED Y <br /> ;ADDITIONAL COMMENTS : ",./ Z.." t .1 ;0z <br /> k PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ?� <br /> ;INSPECTION BY INSPECTION BY �.,�- DATE t-r �' <br /> F14 i 11`J Fi RGU 19_77 � .. '•r - <br /> 1/78 2M <br />