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JAN JUAQUlN LUGAL HLALIH UlJIKll,I <br /> R •OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires l 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 1o. 1862 and the Rules and Regulations of the San Joaquin 4ocal Health <br /> District. <br /> EXACT STREET ADDRESS -] , ,� f CITY/TOW L <br /> Owner's Nameu ,� �a� Phone <br /> Address ,[, Ci ty� 'Yp��F — <br /> Contractor's Nam *License# Phon62. — y4l4 / <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT EJ T <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 .01 <br /> Ind ,s�.trial Cable Tool Dia. of Well Excavation <br /> gestic/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 _ Surface Sea Installed by: <br /> PUMP INSTALLATION: Contractr —� <br /> Type of ump - — 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 Procedure <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 of California. " <br /> I WILL CALL FO -A GROUT INSPECTION PRIOR TO GROUTING AND A NAL INSPECTION. <br /> SIGNED <br /> 1,-- TITLE: DATE ^ , <br /> kvKARIOT PLAN ON REVERSE- SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /6�7 <br /> EH 1426 Rev. 12-77 'V178 2M <br />