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SAN JUAQU-IN, LUCAL HLALIH U15IK1L1 <br />__FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No.?g <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-7-2,7-?q <br /> This Permit Expires 1 Year From `Date Issued <br /> Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br />,oanuin:.County Ordinance Nlo. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS..-,..-a Z , 01Q� CITY/TOWN ' <br /> Owner's Name PhoneLR/0--9`2- <br /> Address-. Z �G City �4 p l <br /> Contractor's Nam ,3 License _ Phone �. '�i-�''' <br /> IS CERTIFICATE Of WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO�� <br /> TYPE OF WORK -Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> In trial Cable Tool Dia. of Well Excavation c'6 <br /> omestic/private Drilled Dia. of Well Casing <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 urface SAl Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proceaure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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 oh California." <br /> I WILL C9t FOR A/GROUX I P CTI0 RIOR TO GROUTING AND INAL INSPECTION. <br /> 5IGNED TITLE• DATE: 2 <br /> -('5RAW PLOT <br /> L N ON REVERSE SIDE <br /> F <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> 4PPLICATION ACCEPTED BY C DiTE /7-7 -47 17 <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY /S - DATE 3 <br />:H 1426- Rev`. 12=77 <br /> 1/78 2M <br />