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/ J)AN JUAQU1N LUGAL MtHL1M U1z, 1K1U1 <br /> FFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�_/s- � <br /> Telephone: (209) 466-.6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/,O(,-t- 7 S' <br /> This Permit Expires I 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 /> tioanuin County Ordinance Iu. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ` <br /> EXACT STREET ADDRESS__/0,9,5-/- -50' -50 CITY/T0W� P <br /> Owner' s Name Z,0,eVft7v Jam; Phone�zf 1 <br /> AddressI/2 <br /> City �'�.�e-w <br /> Contractor' s Name 7r744 nU License# one �I - eM'� I- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 1 ---- ND ! <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT ❑ lr� <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 /> 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 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 H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> F <br /> PUMP REPAIR: Wtate Work Done es y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 /> 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 /> SIGNEDTITLE: DATE: -) �J_�,2_. Z9 <br /> DR W PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY (� DAT—PLICATION .?l 7� <br />\DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . = DATE—//-2,:2 <br />'.H 1426 Rev. 12-77 1/78 2M <br />