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kSAN JUAQUIN LU(:AL HtALIH UISIKILI <br /> FFICE 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 1'/7 <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 /> Joaquin County Ordinance No. :1862 and. the-Rules and -Regulations of the-San Joaquin Local- Health <br /> District. ��c�5 �- = G `:v.v ►� <br /> EXACT STREET ADDRESS nv -4o /TOWN <br /> Owner's Name <br /> Phone 1��S_-_y9��'__` <br /> Address - City <br /> Contractor's Name License# 3 /,11 Phone <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATION INSU ?ICE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION E]WELL CHLOR NATION ❑ WELL ABANDONMENT 0 OTHER p --- <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINE PIT PIT PRIVY <br /> SEWAGE DISP SA ,, FIELD �-�`-CESSPOOL/SEEP/4GE PIT OTHER <br /> PROPERTY LINK' 'PRIVATE DOMESTIC WELLcV — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f IndustrialCable Tool Dia, of Well Excavation <br /> Domestic/private rill ed Dia. of Well Casing,/4/—,/ <br /> Domestic/public DrivenGauge of Casingi , l,4J41LI _ <br /> Irrigation Gravel Pack µ . Depth of Grout Sea <br /> Cathodic Protection Rotary y Type of Grout <br /> t Disposa-1 Other Other Information <br /> Geophysical Surface Seal Installed by: ---- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> r <br /> PUMP REPLACEMENT.:. Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> E Describe Material and Procedure <br /> k. <br /> 4 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 /> I 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 CALL40R A GROUT NSPEC N IO ROUTING AND A FINAL INSPECTION. i <br /> r <br /> k SIGNED TITLE: 14, t.,� DATE: <br /> D W P12T PLAN- ON REVERSE S <br /> FOR DEPTUMENT USE ONLY <br /> PHASE I DATE <br /> PPLIC TION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE ' III FINAL INSPECTION <br /> INSPECTION BY DATE _` *y ~ .INSPECTION BY DATE 2 <br /> } EH 1426 Rev. - 12-77 1/78 2M <br />