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SAID JUAQU1N LUCAL .NtAL1H U1JIKIUI . <br /> - ERQ_ OFFICE U E: 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 ire§ 1 Year' From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit. to construct { <br /> and/or install the work -herei.n described. This application is .made in compliance with San <br /> ,'oaquin County Or.di:nance No. 1862 and , he Rules and Regulations of the San Joaquin Local Health <br /> District. d C� <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s name Phone <br /> Address �� LZ <br /> �-'" City <br /> Contractor' s Name d ensW . Phan <br /> TS CERTIFICATE OF WORKMAN'S C0#iPENSATION INSURANCE FILE WITH SJLHD? YES 4,-�N0 <br /> TYPE OF WORK (Check) : NEW WELL C3----DEEPEN O RECONDITION [3 DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT O OTHER O <br /> PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT1 <br /> DISTANCE- TO NEAREST: SEPTIC TANI SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> --Industrial Cable Tool- Dia. of Well Excavation <br /> zr Domestic/private Drilled Dia. of Well `Casing } <br /> Domestic/public Driven µ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection wry �,f' `Type of Grout y <br /> Disposal Other 1 Other Information ' <br /> 9 <br />_ Geophysical Surface Seal Installed b : cr 3 <br /> PUMP�;I,NSTA'LLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done , <br /> PUMP REPAIR: O State Work Done a <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> fI 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 certifythat in the` e-..rformance of the work for which this <br /> p �� permit is issued, I shall <br /> not employ any person th "such manner as to become subject to Workman's Compensation <br /> laws of Californ-i-a. '� <br /> I WILL CALL FOR A -GROUT INSPECTION PRIOR T,07VOUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: `E <br /> (DRAW PLT L N ON REVERSE SIDE <br /> FOR_DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B� DATE <br /> ADDITIONAL COMMENTS: I 1 <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BYDAT£ INSPECTION-BY DATE -3- -` <br />' EH 1426 Rev : 12-77 _ '' }. .. �, v T ,� r ���q 1/78 2M <br />