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t- SAN JUAQUIN LUGAL ht.AL I H U15I KIU <br /> OFFICE USE: 1601 E. Hazelton' Ave. , Stockton, CA 95205 Permit No.f <br /> Telephone: ' (209) 466-6781 <br /> Date Issued ��' <br />�--- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I <br /> This Permit Expires 1 Year From Date Issued. <br /> i <br /> Complete In Triplicate <br /> Application is hereby made to the San Jo-aquin .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 /> oaquin County Ordinance No.- 1862 and the Rules and Regulations of the San Joaquin Local Health t <br /> n;strict. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Phone <br /> Address City <br /> Contractor's Name License# o Phone b - J <br /> i <br /> TS CERTIFICATE OF 14ORKi,Atl'S ''CO"1PEP4SATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M f DEEPEN ❑ RECONDITION Q� DESTRUCTIONI] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> f PUMP INSTALLATION 0 PUMP REPAIR{$ PUMP REPLACEMENT Ea <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY LLA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTTER <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 Seal <br /> Cathodic Protection Rotary Type of Grout } <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump J.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: L State Work Done 7/uV &V&—� <br /> DESTRUCTION OF WELL: WeTI` Diameter T w Approximate Depth <br /> Describe Material and Procedure <br /> F 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. I- WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNEQ TITLE: DATE: <br /> fl , i + ; ,Fi DR .W, PL T PL N ON REVERSE SIDE <br /> =' 4 FGR<•DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I fig- R <br /> ADDITIONAL COMMENTS: r'' <br /> PHASE II GRO.U71-I.NSPECTI�ON--i PHASE III FINAL INSPECTION <br /> INSPECTION BY -- 'DATE INSPECTION BY DATE—e, <br /> EH 1426 Rev_ 12-77 1/78 2M <br />