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JAIV JUAQuIN LULAL HLAL l H U131 RIL 1 <br /> EOR FFSEU��EE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. n-/095- <br /> Telephone: <br /> /d9,5`Telephone: (209) 466-6781 <br /> '' APPLICATIONFORWELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 /> ,'oaQui n County Ordinance 1�o. 1862 and he Rules and Regulations of the San Joaquin Local Health <br /> 5istrjct. -7$ <br /> EXACT STREET ADDRESS �1,-r C CITY/TOWN <br /> Owner's Name ti Phone - <br /> Address Ci ty <br /> Contractor's NameS�� t� �c_sr+ r�_� _cL-�:oenses ,� 0 Phoneme r-j --3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL L§&1"DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATI 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 SPECIFICATIONS <br /> In ustrial Cable Tool Dia. of Well Excavation <br /> omestic/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 r� f� <br /> Type of Pum _ t� —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 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 mariner as to become .subject to Workman' s Compensation <br /> laws of C lifornia. " <br /> I WILL CALL R A GRQUT. INSPECTIOV PPAOR T ROUTING AND INAC, INSPECTION. �•J <br /> SIGNED TITLE. DATE: <br /> ` �W-FL�0-r'4PL�AN ON REVERS SIDE <br /> ,FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C '7 1 <br /> �XL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA -jjrMAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -21—n <br /> fH 1426 Rev_. 12-77 1178 2M <br />