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r, _0; SAN JUAQUIN LULAL_ HtHL,I H Uli ,I KM I <br /> OFFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. ]y- 3>_c _ <br /> Telephone: (209) 4664781 <br /> = APPLICATION FOR WELL COifS RUCTION OR PUMP PERMIT Date Issued -I -� <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 permi.t. 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 <br /> 'district. r <br /> J � <br /> ACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone 442 - 13_- �-Address C i tya�, •� _ <br /> Contractor' s Name License# 3�nc Phone 3(,�, <br /> ':S CERTiF"ICATE OF WORKMAN'S COF}PENSATIOIN INSURA1110E ON FILE WITH SJLHD? YES 'JO <br /> TYPE OF WORK (Check) : NEW WELLK� "DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION Q WELL ABANDONMENT E3 OTHER F-3 <br /> PUMP INSTALLATION_N _PUMP REPAIR❑ �_. PUMPR�EP,LACEMEIVT <br /> DISTANCE TO NEAREST: SEPTIC .TANK hA,t SEWER PIT PRIVY <br /> SEWAGE DISPOSAL FIELD no CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial >4- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> :; Domestic/pub.� ic Driven Gauge of Casing i a7 <br /> fi ripation-y,' Gravel Pack -Depth of Grout Seal C 1 <br /> ,cathodic" Protection Rotary . Type of Grout q S a <br /> aispos,al,,- Other Other Information X, E <br /> . Ge p ysical Surface Seal Installed. b - <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump _H.P-. I -r- <br /> PUMP REPLACEMENT: p State Work DonePUMP REPAIR: O State Work Done E <br /> DESTRUCTION OF-WELL: Well Diameter - Approximate Depth <br /> D e s c r i be Mate'ri-a -and PI^oceaT re <br /> I hereby certify that I have prepared this appl:ication. 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 WILL CALL !FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: D4 R �_' _ DATE: icl <br /> DR PL T PL N ON REV <br /> FOR PEPARTMENT USE -ONLY <br /> PHASE I // <br /> APPLICATION ACCEPTED B' �° f DATE l7 <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I` INSPECTION BY DATE INSPECTION BY QAT a <br /> CU Innc n, -n --rte: _ �' T 1 T'/7 A 7M <br />