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SAN JOAQUIN LOCAL HEALTH UISIRIC1 <br /> —F0�R FILE USE: V-1 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No..Z2r—4 <br /> Telephone (1�9:9) 466-6781 <br />,�-- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 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. 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_ .y �" - _fi7,�c��1�w,q� - CITY/TOWNj&/Ai&_4 <br /> Owner' s Name_Ze-0 Phonel?`yq=//f f <br /> Addresses City,AVAoAA c _-- <br /> Contractor' s Name License Phone 9!!5/Llz fb <br /> ?S CERTi F ICATE OF WORKMAN-`S COMPENSATIO'll INSURANCE -H FILE WITH SJLHD? YES X NO ---_ <br /> TYPE OF WORK (Check) : NEW WELLVI DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [3 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY V <br /> SEWAGE DIS OSP AL� FIELD CESSP�OI/SEEPA £ PIT OTHER <br /> PROPERTY LINE/Q tPRIVAE DDO9ESTIC WELL � PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 3y` ONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation —,X- Gravel Pack Depth of Grout Seal Si2 r <br /> Cathodic Protection Rotary . `Type of Grout <br /> Disposal __)('-Other Other Information -�— <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 accordancf <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 CAL FOR A 0 IN TION PR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE:/ <br /> DR W PL T L N ON REV SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY IA. DATE Ze <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION U PHASE III FINAL INSPECTION <br /> INSPECTION BY A4 DATE - 7,��j�-7 INSPECTION BY DATE 1a-ZS-78 <br /> EH 1426-_ Rev. 12-77._ ._._:_ � !"' "`c"`b' 1/78 2M <br />