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JAN JUAQU1N LUUAL HLALIM U151KILI <br /> rFOFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Anplication 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 /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of t-he San Joaquin Local Health <br /> District. CS ca O Op `; 5S �Fc)2 P �a <br /> EXACT STREET ADDRESS d �`�� Cr CITY/ <br /> Owner' s Name �o G N� 1Phone_ <br /> Address ,,��11 <br /> �b � U City. 4N-ArM - -- <br /> Contractor' s Name c) W RT License# Phone <br /> 'S CERTIFICATE OF WORKMAN'S COMPENSATION TNSURA'`!CE ON FILE WITH SJLHD? YES 1140 <br /> TYPE OF WORK (Check) : NEW WELL b DEEPEN ❑ RECONDITION (] DESTRUCTION[2 <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK 4f0lb SEWER LINES PIT PRIVY M Q N <br /> SEWAGE DISPOFIELD ' bQ-fEESSPQQL/ E�.EPAGE PITQ'40TH£Rf�g�` (� <br /> PROPERTY LIN PRIVATE DOMESTIC WELL O O 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 Sea <br /> Cathodic Protection Rotary -Type of Grout <br /> Disposal Other Other Information N . <br /> Geophysical Surface Seal Installed by: q W�� <br /> PUMP INSTALLATION: Contractor Q _._. .... . . . , . <br /> Type of Pump - - S H.P. - -_S- - --- - - <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter hTQ WR 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 manner as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL R T SPECTION PR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: L9GCJ/v DATE: <br /> D W POT -PLAIT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION DATE -M-8M <br /> EH 1426 Rev. ISL= �- _. - - - 178 21` <br />