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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 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 Trip icate <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. 496*(19 15. H�taO4y�,76. • deo- Q3 <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner's Name �t�J�M, �f'AJ�tY�r /. - Phone 4'.a/- 3/24' <br /> Address _ /34 7asi.yirty Fi' city c57Yc� <br /> wn-Lrac>:or-s Name , -Llcenseiyjt,7T,r rnone --,'rrri7.r <br /> TS CERTIFICATE OF WORKt1At1'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES / NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN O RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER O <br /> PUMP INSTALLATION 0 PUMP REPAIR"' PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK JvA f SEWER LINES PIT PRIVY <br /> SEWAGE DISP USAL FIELD CESPOOL/SEEPAGE PIT OTHER o� <br /> PROPERTY LINE -. PRIVATE DOTIESTIC WELL PUBLIC DOMESTIC WELL �D <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria— Cable Tool Dia. of Will Excavation_ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> c..- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatlon <br /> Geophysical Surface Seal Insta ed y: pp <br /> PUMP INSTALLATION: Contractor/ to641,41 vawgr 4 4—.04? >/ / —,/ N <br /> Type of Pump_ `tW,r r,, H.P. 9RN- <br /> -PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIR: ❑State Work Donees „A,r. l 1:Ln&-X-r <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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TIT av r DATE: /D,�2,/ >Ir <br /> R W FLUI PEW ON REVERSE SIDE2.. J <br /> FOR DEPARTMENT S ONLY <br /> PHASE I <br /> PPL TION ACCEPTED BY /. , / < _ !� / �� , DATE /' ?� <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1421; Ray 19-77 1/78 2M <br />