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f * S <br /> `L - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. F <br /> Telephone: (209) 466-6781 $ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /-/-5-2z <br /> This Permit Expires .l. 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. . This application is made in compliance with San ' <br /> ,:oanuin County_Ordinance No. 1862 and the Rules and Regulations of the San .Joaquin Local Health <br /> District. ,U 1 �c_c.J r ICI` 141;22.7—2 Y6-Lf-3 <br /> 2nt 2 <br /> EXACT STREET ADDRESS �w CITY/TOWN <br /> Owner' s Namet��,��tiy��,� - L/ rte. Phone 'I <br /> AddressAddresSL, City <br /> Contractor' s Name_ `7r s� � ,�, _ _ License#,?7 Phone <br /> IS CERTIFICATE OF WORKMIAN'S C0 PENSATI0'l1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> 1'Y4 OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ F <br /> PUMP--l-NSTAL-LATION ❑ PUMP REPAIRRR PUMP REPLACEMENT {EI <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.ALINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Di a. of Wel 1Casj�-Vg;. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ==. ----Depth—o.fGr_o.ut--Sea- _.— <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal ,.0ther Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor _ <br /> -� % Type of 4Pump r''. t H. <br /> PUMP-�,REPLACEMENT.: ' ; Q State-Workr Done I <br /> PUMP REPAIR: _ ( State�Work Done. ---- �' <br /> :. <br /> DESTRUCTION�OF WELL: Well Diameter -= " , . Approximate Depth _ <br /> Describe Material 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. 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 in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL A GROUT INS TIQW PRIOR TO GROUTING AND A FINAJ INSPECTION. <br /> SIGNED TITLE: DATE: - =- <br /> DR W PLOT PLTN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I t �1 DATE ��-37 --- <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS : <br /> INSPECTION BY <br /> I•I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ` �� INSPECTION BYli✓ _DATE —S � <br /> IFN -7a9F Ratr ,7_77 1/72M <br />