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� 5AN JUAQUIN .LUGAL HLAL I11 01J 1 K11,1 <br /> rI � FFICE USE: <br /> r 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. , l ,2- <br /> Telephone: (209) .466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1p-3/- <br /> This Permit Expires 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 install the work herein described. This application is made in .compl,iance with San <br /> �'oaquin County Ordinance No. 1862 .and� the Rules. nd Regulations of the San Joaquin Local Health <br /> District. /0/$ S <br /> EXACT STREET ADDRESS <br /> CITY/TOWN --s <br /> Owner's Nance Phone <br /> -� � <br /> Address S-9-�City <br /> Contractor's Name & OaJ 114License Phone <br /> `S CERTiF'ICATE OF WORKMAN'S COMPENSATION INSURANCE 9N FILE WITH SJLHD? YES + NO <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> ,WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 1 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK/ l SEWER 'LINES PIT PRIVY. <br /> SEWAGE DIS OSP A!, FIELD_/,oD74 CESSPOOL/SEEPAGE-PIT !---OTHER <br /> PROPERTY LINE/&'IPRIVATE flOMESTIC WELLPUBLIC DOMESTIC WELL "� <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 u <br /> Domestic/private Drilled Dia. of Well Casing =• <br /> Domestic/publ-ic Driven" Gauge of Casing .� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic' Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: '. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and Proce ure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accorda m. <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 CAL OR A GRO T INSPE 1/ 0 SPR , ATO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: qa DATE: 0, <br /> R PL T PL N ON REVER SIDE 1 - ` ~ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - - INSPECTION BY �/f� DATE — <br />:H 1426 Rev_ _1.,x_77 � '" T �/2 W/�Trt/)IL/G-rk <br />