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SAN �A .f u1 <br /> FQR FFICE USE: 1601 E. Hazel tor=r,-ve. , Stockton, CA 9520 Permit No.Zf-/4 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . <br /> Date Issued 3- -7 T. <br /> This Permit Expires 1 Year. From Date .Issued , <br /> Complete In Triplicate ' <br /> lApplication is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein. described. This application is made in compliance with San <br /> ,;oaauin County ,Ordinance hyo x 1862 and the Rule's and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOW <br /> Owner's Name L417, Le <br /> . - Phone � f <br /> Address City - <br /> Contractor's Name <br /> License `�lZ Phone�g '�� <br /> TS _C£RT_T-FTCATE. OF WORKPlAfI'S_ COIvIPENSATTO'J INSURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL,W DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLl7RTNATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST.: SEPTIC TAN _ 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 SPECIFIC TIONS <br /> Industrial Cable 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 Suri-ace Seal Installed by: <br /> PUMP INSTALLATION: Contractor H. . <br /> Type of Pump �' ' <br /> PUMP REPLACEMENT: ❑State Work Done t <br /> 'PUMP- REPAIR: v ._ O State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby certify that I have prepared this appli-cation and -that` the work will be done in atco H anc <br /> 1with 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." 418- <br /> .. <br /> I WILL GAL A GROUT INSPECTI PRIOR TO GROUTING AND A FINAL_=INSPECTION. <br /> SIGNS _ '.:` ` `,at ,� TITLE ti�i'L�, ` O DATE: <br /> i Y DR `PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> • PHASE I � `�' <br /> APPLICATION 'ACCEPTED BY{ DATE <br /> ADDITIONAL COMMENTS: ., <br /> PHASE II,;.GROUT=,INSPECTI N PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE_ INSPECTION BY DATE <br /> EtU 1AOC ❑. 113 -77 - .. _ - 1 78- 21:.L_ <br />