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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. / 1 /a- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /O-3 7R' <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 instal ' 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 /> L'istrict. / GY �o 'E- . <br /> EXACT STREET ADDRESS �ir �, rr / - / r.,, f � ,..f Jl CITY/TOWN `�.. Td ✓ <br /> Owner's Name AALig(r, Eki-el #f,rZ. . _ Phone <br /> Address - /3�zS—q oe? city <br /> wn-e a"or--s name V—A?, V7 i7 it/ Licensefj—,r-7 r wnone yj rT ram <br /> IS CERTIFICATE OF WOPKt1AN'S C011PENSATION INS11RA10E ON FILE WITH SJLHD? YES L/ 'JO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR OR-- PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,fa± i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatlo—r n <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor 1/,v„rs0,150>,( <br /> Type of Pump y , , v H.P. -5-07in <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Donee, f, ./ !�c•G � f <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 J � ' . mac. TIT c� e.v i DATE: G ? <br /> (DRAW FLUI FLAN ON RE RSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY / <br /> e <br /> APPLICATION ACCEPTED BY �, /i /f/_� DATE ' �f <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1426 Ray 19_77 .--- ----- _._. .--- -. . .-_ _._._-- --- 1/78 2M <br />