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SAN JUAQUIN-LUCAL HLALIH U1JIK1U1 <br /> FOR FFICE- USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -jy - b10 <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 6-�+<�-7 f <br /> This Permit Ex ires 1 Year from Date Issued <br /> Complete. In Triplicate <br /> , .Avplication is hereby made to the San Joaquin Local Health Districtfor a permit to construct <br /> arid/or install the work herein described. .- This application is made in compliance with San <br /> L"oaquin County Ordinance No! 1862 and the Rules and Regulations of the San Joaquin ,Local' Health <br /> Diistri ct, i Ln7-�F <br /> EXACT STREET ADD S5 9� <br /> CITY/TOWN <br /> Owner' s Name <br /> Phone <br /> Address. - City <br /> r <br /> Contractor' s Name I''; Li cense Phone = S -3 <br /> _IS CERTIrICATE OF WORKMAN'S C01,1PENSATI01"1 I"JSURA*ICE ON FILE WITH SJLHD? YES NO <br /> h ^- <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> W WELL. CHLORINATION ❑ WELL ABANDONMENT 0 ...OT,H;ER 0- <br /> PUMP <br /> PUMP INSTALLATION CK PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST �S:EPTIC-TANK- SEWER-LINES PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD ; CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well,`Casing i <br /> Domestic/public Driven � Gauge of Casing <br /> Irrigation Gravel--Pack--- Depth of Grout Seal <br /> Cathodic Protection 'Rotary - Type of Grout <br /> Disposal Other .: Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Do e 3 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 'Depth_ <br /> Descfi-be-Materi-a -and-Procell"arei.j. F '% <br /> I hereby certify that I have prepared this application and that the work will be done in accordai <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <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 GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: err DATE: (a— 9-22 <br /> ��DRWPLTL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY��DAT�DAT� <br /> ' F <br /> 2T <br /> FN 1A29 Rau 1 9_77 1_./,T8-, <br />