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looi E. Hazelton Ave. ,(2 Stockton. CA 95�s5 Permit No. a G / <br /> Telephone: (209) 466-6781 <br /> APPLIC71`iION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-l-_2,2-79 l <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> JoaquiniCountyl OrdinancehNo 11862sandbthe Rules andlRegulations ofethe SanpJoaquinwltcalaHealth <br /> District. <br /> EXACT STREET ADDRESS--- {30o E �G/4r v, u.Jtz y�Ep CITY/TOWN <br /> Owner's Name <br /> Phone <br /> Address_ .2 4 a„ dCity Jr i4+-- <br /> Contractor's Name a LicenseM /21-7i1'Phone_ ci1L3--7G7>S <br /> IS CERTIFICATE OF WORIQIAN'S C iP NSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION Q DESTRUCTION ) ' <br /> W <br /> 13 •i <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER❑ 9 <br /> PUMP INSTALLATION ® PUMP REPAIR Q PUMP REPLACEMENT ❑ S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWPROPERTYI .INNE PClELD MSEEPAGER <br /> RIVATE7WESTIIWELLPUBL7 FRESTICGE= <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> n ustr a —Na61e Too-1 Dia. of We xcavat on <br /> __;Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Tea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informat own— -— <br /> Geophysieal _Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP @> 469T: ®State Work Done _Z/ ,ilea , "��.,, ;, Nf, i t, <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Materfa7 anF7rocedure <br /> I hereby certify that I have prepared this application and that the work will be d-ne 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,,POR A GROUT INSPECTION PPMD TO ROUTING AND A FINAL INSPECTION. <br /> SIGNE E: /tJ DATE: / <br /> REV S <br /> D N S N <br /> PHASE I <br /> ATFL. !'TION ACCEPTED BY 1J DATE 3 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III -FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE A tom <br /> -H 14 26 Rev. 9/78 9/78 2M <br />