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r JAN JUAQUIN LUCAL Mt`HL f H Uli ,I KIL I <br /> FOR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. p <br /> i <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 /> % oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin total Health; <br /> nistrict. - . j <br /> EXACT STREET ADORES / CITY/TOWN <br /> Owner's .Name �, ,,, Phone Xe3-yd:8 <br /> Address 7 City �' cicac <br /> Contractor's Name tAcfa it a P. X License# 3 ele2 Phone tfGS"= 378 <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION IINSURA110E ON FILE WITH SJLHD? YES 1140 X <br /> TYPE OF WORK (Check) : NEW WELD DEEPEN Q RECONDITION d DESTRUCTION[), V <br /> WELL CHLORINATION Q WELL ABANDONMENT M OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR Q PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES 75-1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT tao_r 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 Ilk IV <br /> Domestic/private =Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation _x9ravel Pack Depth of Grout Seal �d f <br /> - Cathodic Protection Rotary . 'Type of Grout e; <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed, b : <br /> PUMP INSTALLATION: Contractor ccnow, <br /> Type of Pump r H.P. a <br /> } r• . <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q 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 accordant( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ! <br /> Health District. Home owner or licensed' ag�nt' 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 i <br /> laws of California. " -- { <br /> I WILL CALL FOR A GR UT 'INSPECTtION PRIOR TO GROUTING AND A FINAL iINSPECTION. <br /> SIGNED .TITLE d-&-L�k 0V DATE: 111-7179 <br /> DR W PLT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY _ - . <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,,., DATE <br /> ADDITIONAL -COMMENTS: <br /> PHA E II GROUT IN PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - 6-7 P INSPECTION B ', - DAT E.//-4 2 <br /> FH I d9A Poll 19-77 u <br />