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SAN JUAQUI.N LULAL HLALIH L11SIKILI <br /> BICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.29_,/a-�- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSfRUCT4ON OR PUMP PERMIT Date issued g-7 9 <br /> This Permit Expires 1 Year From Date -Issued <br /> Complete In Triplicate <br /> Aoplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> drid/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 <br /> C?strict. <br /> ' CITY/TOWN <br /> }(ACT STREET ADDRESS_ ¢ [ - ;'yl �� <br /> Owner's Name A Phone m? <br /> y <br /> ,�Address f, City <br /> Contractor's Name License#va qc�?%yy Phone_. <br /> IS CERTIFICATE OF WORKMAN'S C0"1PENSATION INSURAINCE ON_FILE WITH SJLHD? YES <br /> TYq "OF—WORK -(,Check) : NEW`WEL04 - '_`DEEPEN El RECONDITION ❑ ­.-DESTRUCTION-0 <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER F-1 . ~'- , - , <br /> PUMP INSTALLATION Q , PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK .5 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALIFIELD CESSPOOL/SEEPAGE• PIT OTHER ' <br /> PROPERTY:LINE ,- PRIVATE DOMESTIC WELL.— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEOF WELL "-,—­--- ,CONSTRUCTION SPECIFICATIONS <br /> Industrial X_Cable Tool ., Dia. of Well Excavation 3 " <br /> Domestic/private DrilledDia. of Well Casing ,a. <br /> Domestic/public Driven Gauge of Casing <br /> )1� Irrigation Gravel Pack Depth- of Grout Sea man _ <br /> Cathodic Protection Rotary , "Type of Grout h <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: Q State Work Done 5 <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 , an'd -Rules and Regulations of the San Joaquirn- 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, -1 shalli ' r <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> JA <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: s <br /> f � <br /> (DRAW PLOT PL -N- ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />-Ai',PLI-CAT-I­ON--ACCEPTED BY -._._.:. ./t c� "-" <br /> ,AD_DIT_ibNAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE--7- <br /> EH <br /> ATE -7-EH 1426 Rev_ 12-77 _ _ 1/78! 2M!_j <br />