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r SAN JUAQUIN RUGAL; KLAL I H WS I KM I <br /> FFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit Na. .,��ss� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued �� <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 /> acid/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 r <br /> District. r <br /> EXACT STREET ADDRESS f in &L L 4 CITY/TOWN <br /> Phone <br /> Owner's Name Mg . F96 <br /> Address i'n <br /> City <br /> Contractor' s Name T �,�c�7` 4-S10 Li cense#2 0)0 Phone �8` 6 -;,220: 7 <br /> TS CERTIFICATE OF WORKMAN'S CO"IPENSATIO'! I'3SURNICE ON FILE WITH-SJL-HD? YES <br /> TYPE OF WORK -(Check) : NEW` tiELL 0 DEEPEN Q RECONDITION ❑' DESTRUCTION[3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHERI_ <br /> PUMP INSTALLATION 0 ' PUMP REPAIRIR PUMP REPLACEMENT � <br /> DISTANCE TO NEAREST. SEPTIC TANK 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 _ '-- eONSTRUCTION SPECIFICATIONS <br /> Industrial , � t , -Cable Tool— Dia. ofxWell Excavation <br /> Domestic/private: Drilled, Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Packs Depth of- Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> II Disposal Other Other Information <br />! Geophysical Surface-,Seal 'Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum .. P <br /> Pump <br /> PUMP REPLRCEMENf�__ Q State Work Done <br /> PUMP REPAIR: rRstate 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 FOR A GROUT NSPECTION PRIOR TO GROUTING ANDA INAk INSPECTION. <br /> SIGNED <br /> TITLE: DATE: - _A <br /> (DR-M-PLOT PLTR ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �S� 7_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTIO !„ <br /> II INSPECTION BY DATE:, INSPECTION BY DATE Y <br /> r <br /> k, mkt , AnC ,n 178 2M <br />