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' SAN JUAQUIN LUGAL HtALIH UI5IKILi <br /> TOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No.7 % <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued ,7-s-7'? <br /> This Permit Ex ires, '1 Year-From Date Issued <br /> Complete In Triplicate <br /> ' Ap;plicatfon is hereby made to the San Joaquin ,Local Health District for a permit to.construct <br /> an'd/or Install the work herein described. This application is made in compliance -with San <br /> "da-nu i'n County Ordinance IV. 1862 and the Rules :-and Regulations of. the San Joaquin, Local Health <br /> Cistr�ct. -2-3 DU3r rr <br /> E•XACT STREET ADDRES ,CITY/TOWN vv!2 i�, <br /> Owner' s Name y' t, w <br /> Phone S(n <br /> Address ` ` City 77 " <br /> - <br /> ' Contractor' s Name , LicenseQ� Phone <br /> 15 CERTIFICATE OF WORKMAN'S VMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : --NEW WELL❑ DEEPEN ❑ _RECONDITION'C]—DESTRUCTION[]° <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION [�MP REPAIR❑ PUMP REPLACEMENT ❑ �, <br /> r f <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PR`IVYI t s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIMATE DOMESTIC WELL PUBLIC DOMESTft`WELL Ilk <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool m Dia. of Well Excavation ��- <br /> r�Domestic/private Drilled = Dia. of Well Casing <br /> Domestic/publ i c Driven Gauge of Casing 's <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ,..t Rotary Type of Grout <br /> Disposal er Other Information <br /> Geophysical Surface Seal Installed b <br /> POMP INSTALLATION: Contractor <br /> Type of Pu 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 accordan <br /> with San Joaquin County Ordinances , State Laws , a'nd Rules and Regulations of the San Joaquin Loca <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 lifornia." <br /> iI WILL CA OR A GRO T INSPECTI IOR GROUTING AN INAL INSPECTION. <br /> SIGNED TITLE yC DAT ..�� <br /> R W L T PLAN ON REVERSE SIDE <br /> ' FOR DE ART ENT US ONL'.Y <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> �RDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION , PHASE I I EINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . ,DATE: <br /> x/n78 <br /> 2M <br /> IN 14?ti Rav_ 12=77' <br />