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cam- <br /> SAN UUAQUIN LUL:AL HLALIH Ui51KIl l Permit N0.FQR <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: (209) X66-6781 <br /> Date Issued -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex I-es- 11'Year From pate issued <br /> Complete In 'Triplicate <br /> Application is hereby <br /> made to the San Joaquin Local Health District for a permit to construct 3 <br /> and/or install the work herein described. This appol•ication nsis modfethe San in pJoaquin wLocal ith aHealth <br /> ,oanuin County Ordinance ri <br /> 1862 and the Rules an g <br /> uistr;ct. CITY/TO;RS <br /> EXACT STREET ADDRES 4_ Phone <br /> fOwner's Name Y � L <br /> � ..� City <br /> ens <br /> IIAddressI � Phone5`V--� <br /> Contractor' s Name �- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"NCE OTJ FILE IrJITH SJLHD? YES <br /> TYPE OF WORK (Check) : NE <br /> W" WELL DEEPEN ❑ RECONDITION Q DESTRUCTION F1 <br /> WELL CHL0RINATIO WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATI PUMP REPAIR❑ PUMP REPLACEMENT ❑SEW <br /> I off. <br /> DISTANCE TO NEAREST: SE AGE DISPOSAL FIELDTNKER LINECESSPOPRIVYPIT <br /> OL/SEEPAGEPIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL , <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I ustrial Cable Tool <br /> Dia. of Well E aviation { <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gaugerof Casing <br /> Domestic/public . <br /> � Gravel Pack Depthof Grout Seal <br /> Irrigation Type <br /> of Grout ,+ <br /> Cathodic Protection Rotary <br /> er. Information <br /> Disposal Other <br /> Surface Seal Installed b <br /> Geophysical <br /> PUMP INSTALLATION: Contractor 1 v-' `-'�'► - <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑state Work Done _ <br /> PUMP REPAIR: ❑State Work Done <br /> Approximate: Depth' <br /> IpESTRUCTION OF WELL: pescrDbemMateria an eter Procedure <br /> rat application and that the work will be ,done in accordar <br /> I hereby certify thI have prepared this <br /> .with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the`5an Joaquin Loci <br /> Health District. Home owner or licensed agent' ssignature <br /> w <br /> ahcertifies <br /> the <br /> following: <br /> issued <br /> ichthispermitis , I shall <br /> "I certify that in the performance of the work <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of C lifornia." <br /> I WILL CALL R A G 0 T INSPECT O RIO V, O,GROUTING AN4EI <br /> NAL INSPECTION. M 7� <br /> // TITLE' DAT ,cr <br /> SIGNED G O7 PL N ON REDE <br /> FOR DEPARTM NT USE ONLY <br /> PHASE I „� DATE - �y <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pHq II NAL INSPECTION <br /> PHASE II GROUT INSPECTION ON <br /> `INSPECTION BY MATE INSPECTION --� <br /> 1/78 _ Z <br /> -7-7 ... <br />