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—�� Jltt V V(1tjV a"1\ LVI.lIL I IL/\L I I I Ul J l l\l V l `�- <br /> P. OFFICE USE: 1601 Hazelton Ave. , Stockton, CA 4�5 Permit No. <br /> Telephone: (209) 466-6781r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �7"70 <br /> This Permit Ex fres 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 Regulat' ns of the an Joaquin Local Health <br /> District. �-Z3q 3 s , CeAAA �- /VW V <br /> EXACT STREET ADDRESSZ6"{' $ ��,rh�rGb��,�.[ IfoiIR�4'C lam, CITY/TOWN <br /> Owner's Name v Phone ?S - 9 4 q <br /> Address City_ r <br /> Contractor's Name $ icense Phone ¢/J=� S <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA1110E ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WORK (Check) : NEW WELL K DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ ' OTHER ❑ <br /> PUMP INSTALLATION P9 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIT NK Lo0/ SEWER LI I,ES�J__ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /DO CESSP OL/SEEEPAGGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL - 4-- PUBLIC D MESTIC WELL s <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 -7`—Other Other Information <br /> Geophysical n Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor AL <br /> Type of Pump ..F 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 accord nc <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 FOR A GROUT INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: vi DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> PPA LICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION PHASE, III F NAL INSPECTION <br /> INSPECTION BY DATE f/ 7 — . I .NSPECTION BY< v, DATE 70 �c� <br /> EH 1426 Rev. 12-77 1 /78 2M <br />