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JAN JOAUU1N LULAL HtALIH U1�iK11.I <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._Z,1L_1,W f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 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 4nstall the work herein described. This application is made in compliance with San <br /> �oan'.:in County ordinance ':u 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> :.'�Str•C:. <br /> EXACT STREET ADDRESS O _ CITY/TOWN <br /> Owner's Name <br /> Address �{ City — —�— <br /> Co^tractor's Name �1! Q� C/ icense#,*L y 4 ,'57Phone <br /> IS CERTIFICATEOF WORIQIAN'S CO'4PENSATIOt1 I"1SURA'ICE"Otl FILE WITH SJLHD? YLS I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN O RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION O WELL ABANDONMENT O OTHER O <br /> PUMP INSTALLATION O PUMP REPAIR O PUMP REPLACEMENT O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE OISP SAL CWWELLP <br /> SEEPAGEUBLR-DJO EOSTICRWELL � <br /> PROPERTYLINE PRIVATE-79ESTI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SF"CIFICATIONS <br /> In ustr 7a ' <br /> Cable Tool Dia. of We Excavation <br /> z--4--0omestic/private Drilled Die . of Well Casing <br /> Domestic/publicDriven Gauge of Casing [ OF <br /> Irrigation --Gravel Pack Depth of Grout ea C <br /> Cathodic Protection t.--Rotary Type of Grout <br /> Disposal Other Other Information <br /> r Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H' ' <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximati Depth <br /> Describe Materia and Proce ure <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 Lai- and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agc 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> W PLOT7_LW ON REVERSE SIDE) <br /> OR DE ME ONLY <br /> PHASE I nDATr rl .y <br /> ATP_L_ �ICYION ACCEPTED BY �l °^' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IrSPECTION PHASE III �AL PECTION <br /> INSPECTION BYDATE INSPECTION BY ATE - —7 <br /> 1 /78 2M <br /> �y !426 Rev. 12-77 <br />