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SAN J0AQU1N ,LUI;AL ,HEAL1H UISIKILl <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: . (209) 466-6781 <br /> a C40 APPLICATION FOR WELL CONSTRUCTION` OR PUMP PERMIT Date Issued y <br /> This Permit 'Ex i res I Year From .Date . Issued <br /> Complete In Triplicate ,. f <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 incompliance: with San <br /> ,1oanuin County ,erdinance ;Igo. . 1862. and thRules and Re ulat'o s of the S n Joaquin Local Health <br /> D i s t r i c t. �EXACT <br /> STREET ADDRESS CITY/TOW�)7w "! lm <br /> Owner' s Name ` �� r �v� i�s Phone d? of <br /> Address A51)9 U?'h� .,� City <br /> Contractor's Name ,5,7- U �,p S License#/6;-373 Phone � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJL•HD? YESv' NO <br /> TYPE`OF-WORK -(-Check) .~- NEW WELL C DEEPEN �1 RECONDITION ❑ DESTR ON <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER EJ s <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT FLI <br /> DISTANCE TO NEAREST: SEPTIC TANKIA4 SEWER LINE !--)A;�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 SPECIE IONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omes.tic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigationgravel Pack Depth of Grout Seal <br /> Cathodic' Protection . ✓ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP, INSTALLATION: Contractor <br /> Type of Pump M.P. <br /> PUMP REPLACEMENT: Q State Work Done <br />' PUMP REPAIR: ❑State Work Done . a <br />.DESTRUCTION-AF WELL:-� Wel1 Diameter Approx-fmate—Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> 1Health 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 /> r 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 /> ,DRAW PLOT PL, N ON=REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BY DATE 7k <br /> ADDITIONAL COMMENTS: , <br /> PHAS II GROUT INSPECTION s • :` PHASE I FIPL INSPECTION <br /> INSPECTION BY ¢ DATE 2­?—?T INSPECTION BYA2Z2LZ2 DATE • 2 <br /> EH 1426 Rev. 12-77 C��O ' 177 2M <br />