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r = w.._ .. .. .. -.. <br /> 'r- bAN JUAQUIN LUUAL MLALIM UI�PIMIU+ <br /> FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. 71 <br /> ' Telephone: (209) 466-6781 <br /> iL APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued & zk-�q <br /> This Permit Ex ires. l Year From Date Issued r <br /> Complete_ In Triplicate <br /> ADplication is hereby made to the San Joaquin Local Health District for a <br /> permit to construct <br /> dnd/or install the work here in 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. <br /> � <br /> EXACT STREET ADD SS ` <br /> CITY/TOWN_ <br /> Owner' s Name Phone <br /> Address <br /> City <br /> Contractor' s NameA. License <br /> _4�ao.!�3 Phone-6-Ls'!;Zrs-93 <br /> _r5 CCRTIFICATC OF WORKtIAN'S COMIPENSATIO'N INSURA"10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) N ' 7WE!-L Q DEEPEN 0 RECONDITION ❑ DESTRUCTION C3 <br /> �- WELL CH-LORINAT•ION-0 WELL ABANDONMENT © OTHER <br /> i <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT ❑ � <br /> DISTANCE TOoNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAG-E._ PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL P[16L_IC- DOMESTIC WELL <br /> INTENDED U'SE- - , -TYPE OF WELL. CONSTRUCTION SPECIFICATION <br /> Industrial CabS <br /> -Te Tool Dia. of Well Excavation <br /> ---,&-Domestic/private — ,.;•.-V Drilled, _ -Dia. of Well Casing <br /> Domestic/public Driven y Gauge of Casing <br /> Irrigation Gravel Pack �­ Depth of Grout Seal <br /> Cathodic Protection Rotary 'Type of Grout <br /> --77:--Disposal Other Other Informati-on <br /> GeophysicalT .L,�Su.rface=Sea.l''I=is_talled by: <br /> PUMP INSTALLATION: Contractor <br /> Type of PuFp= H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: O State Work Done <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 accordant` <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 F GRO T INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNS TITLE: DATE: 6- <br /> ::=R PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ._ <br /> PHASE I <br /> APPLICATION ACCEPTED BY D , DATE Ip 6 <br /> 4UDITIONAL COMMENTS: �. <br /> PHASE II GROUT INSPECTION PHASE IIJ FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY ' DATE 7%' , <br />:H .1426 Rev. I2-77 CD <br />