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r JAN UUAQUIN LURAL HLALIN U131KIL <br /> ;—EOR „QFFICE USE: a 1601 E. Hazelton Ave. , Stockton, .CA 95205 Permit No. 9 <br /> Telephone: (20.0)' 466-6781 _ <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip3'icate <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health.. - <br /> �'�strict. p+. 3-�-- + <br /> EXACT STREET ADDRESS A4a .Q x ppcArl-1— CITY/TOWN y <br /> Owner's Name �r Phone $`3� '; <br /> Address '- L.0 ! ,ST _ <br /> City <br /> Contractor's Name D. L i c e n s e#13-0-00-,�r PhoneR3:i�4, _z / <br /> IS CERTIFICATE OF JORKMAN'S COPIPENSATIO"! IINSURA^ICE ON FILE WITH SJLHD? YES 4 .40 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ .-. <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br />, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-,SPEC-I-SPE <br /> Industrial € Cable Tool Dia. of Well Excavation <br />,Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation --Gra-vel-.Pack-- ,r-.-Depth-of-Gro ut-Sealy <br /> Cathodic Protection Rotary . `Type of Grout <br /> Disposal Other s Other Information <br /> Geophysical, f Surface Sea] Installed by: <br /> PUMP INSTALLATION:—, Contractor <br /> r Type of Pump H.P. <br /> w <br /> PUMP REPLACEMENT: ;r` , ❑State Work Done <br /> PUMP REPAIR: I O State Work Done <br /> f I <br /> DESTRUCTION OF WELL�: 1 Well Diameter � � ��. 1"Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc$ <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."I .; <br /> I WILL CA GROUTINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SI TITLE: . DATE: —7 <br /> �D�RWLOT �LN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DRTE �� <br />.EH 1426 -.-Rev-. 12-77 C01 /78 2M <br />