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r qAN JOAQUIN LOCAL HEALIH UISIRI( ' <br /> FEICE USE: 1601`,,. Hazelton Ave. ; Stockton, CA "0205 Permit No.zk:Z -.4 2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fres 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 /> dnd/or install the work herein described. This application is made in compliance with San <br /> ,:oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. / <br /> EXACT STREET ADDRESS ,2� SE;� �� �an CITY/TOWN r,--,.N <br /> Owner' s Name �f oLw � ✓r Phone <br /> Address Jok city�Frc.i <br /> Contractor' s Name ' License ?S(,//4'1 Phone tZz/Ij- z�12_ <br /> '.S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE 1 FILE WITH SJLHD? YES )e NO <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C=J OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS-Zi SEWER LINE�SU r - PIT PRIVY U <br /> SEWAGE DISPOS L FIEL4�) CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINR'—-PRIVATE DOMESTIC WELL r PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation J9 t <br /> _Domestic/private Drilled Dia. of Well Casing ;' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Informatio <br /> Geophysical Surface Seal Installed by: c-k,Xl a <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 accordant <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 CA R A GR UT ASPIXWON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: e DATE: / <br /> DRAW PL-97 PLAN ON REVE S SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> —4tX/2ff, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY N c ,, DATE__Ll l —A -17 S INSPECTION BY G DATE/ S Zn <br /> EH 1426 Rcv 17-77 II?b i iia �iFf <br />