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SAN JOAIQUIN,LOCAL HEALTH DISTRICT <br /> fFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9_ <br /> :� Tel ephone: �2Q9�.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> y a <br /> T67's Permit .Ex'ires' 1 'Year,Erom Date Tssued <br /> ete In rip �cate <br /> Application is hereby made to the San.Jdaquin Local .Health Distri.c o 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. ,cam, <br /> EXACf STREET ADDRESS <br /> Owner's Name CITY/TOWN =� , <br /> Address Phon <br /> S� _ ..City ' <br /> Contractor's Name ¢-icense# 1 <br /> IS CFRTTFTrATE Or tJOl;KttAN'S COIIPENSATIO�J If1SU �Fione -337 <br /> RA�dCE ON FILE WITH SJLHO? YES <br /> No <br /> '.TYPE OF"'_wORl("rMheck) : •-NEW-WEL`f:Q•-. <br /> DEEPEN-0- "J ECONOITION <br /> TID HCTIONWELL CHLORINATION Q WELL ABANDONMENT OTEPUMP. INSTALLATION Q PUMAR£PAIR(] P REPACEMENT [] �•;,��:�; <br /> ; <br /> DISTANCE TO NEAREI,;.anSfPTI TANK/M SEWER LIDS <br /> .EWAGEaDI PIT PRIVY �, <br /> SPOS L IELD �,CE SP L/SEEPAGE -PTT— OTHER ��r <br /> PROPERTY LINE -. RIVA 1E_ {�MESTIC WELL PUBLITDWESTIC <br /> INTENDED USE .' ; <br /> . n ustrial "YP OE SELL- # CONSTRUCTION-SPECIFICATIONS <br /> '` ab a ao <br /> � c/private - Dia. of a xcavatian s� <br /> omeTt4 `� Drilled Dia of Well _Nil <br /> fi <br /> - Castngr a� _/N <br /> �"`C ams,n "`. ,� <br /> IrrigaTian _ '""�Orave� lac&` ""Depth of Grant Sea ' <br /> Cathodic Protection _ Rotar <br /> .�isposal Other Type of Grout <br /> Geophysical --�-�. Other Information WicL ir! :/ <br /> Surface Seal Insta a <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump •P• <br /> PUMP REPLACEMENT; ❑State Work Done <br /> PUMP REPAIR: ❑State Work Dane <br /> .4EST.RUCT.ION_t1F---dELL:--. -WeJ2,,D1ameter -d.— ,_ 7 <br /> } Describe Mater a an roce ure �' `' p-roxi.mat�e;;[}ept s_ <br /> I hereby certify that I have prepared this application and that the work will '1' <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San eJoaq inaLocalI <br /> Health District. Hame, owne,r or licensed agent's signature certifies the following: <br /> "I certify that fig the performance of the work for which this <br /> not employ any person in such manner as to become subject to Wa Workman's Compenermit is sational) <br /> laws of Californi'a." ' <br /> I WI� <br /> LL CAL FOR A GROUT INSPECTIONi <br /> PRIOR T <br /> 0 GROUTING AND A FINAL INSPECTION. { <br /> S.I GNEO <br /> TITLE; 3 �9 <br /> ` L ON REV RS S DATE ,} <br /> PHASE I R U L { <br /> PP�LICATION ACCEPTEY <br /> A(P0J)TIONAL COMMENTS:. B r 9 <br /> PHASE IT G Ola INSPE PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION 8 DATE r <br /> �H •1426 'Rev.- 12-77 _ <br />