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V/ SAN JUAQUIN 4UGAL HtAL1 H U1J I KIU 1 141'4 1Z <br /> FOR OFFICE USE. 1601 E. Hazelton Ave.-, � <br /> Stockton, CA 95205 Permit No.7g_ /y/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued 7� � <br /> (Complete In Trip icate <br /> Application is hereby made to the San Joaquin Local HealthDistrict for a permit toconstruct <br /> acid/or, install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'district. <br /> EXACT STREET ADDRESS O S"s" G ,\ CITY/TOWNCtl Gb/J <br /> Owner's Name Phone-5'7�F- 2f'7J <br /> Address �� �4(a� 1� City_ <br /> Contractor's Name l v tiles License# Phone <br /> 'S CERTIFICATE OF WORKMAN'S COPtPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) - NEW WELL 0 DEE PEN ❑ RECONDIT-ION ❑ DESTRUCTIONE2 WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER El � <br /> PUMP INSTALLATION,a PUMP REPAIR O PUMP REPLACEMENT,[3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP S� AL FIELD CESSSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabs a Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary , 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 0 w A,-A_571� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: El State Work Done <br /> PUMP REPAIR: ❑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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE::' <br /> R L N ON REVERSE SIDE <br /> R DEPARTMENT USE NLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6ZeeDATE 1--22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION � <br /> INSPECTION-BY DATE INSPECTION BY DATE 0Z ^�r <br /> EH 26 Rev. 12-77 1/78 2M <br />