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5AN JUAQU I N LUCAL HLAL I H U l5 I RI U I <br /> FOP—LOFFUE USE: 1bO1 E. Hazelton Ave. , Stockton, CA 95205 Permit No 7Q <br /> Telephone: (209) 466-6781 <br /> Date Issued 3/3 7S/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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. <br /> EXACT STREET ADDRESS ��y �!L Z1 �„�� ��. CITY/TOWN <br /> Owner's NamePhone �� 3 z2. <br /> Address <br /> 421-26 ,!L ld/ 41 City <br /> Contractor's Name LicenseI3, ,Z& z Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURA,ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLEI DEEPEN 0 `RECONDITION 3 DESTRUCTION d1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: . SEPTIC TAN SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELDCESSPOOL/SEEPAGE 'PIT -- OTHER <br /> PROPERTY LINE-;7PRIVATE DOMESTIC WELLC6_. PUBLIC DOMESTIC WELL -- <br /> INTENDED USE - TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.---of Well Excavation .� <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection -- _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 accordance <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 G OUT InP2C-61ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLT L N ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTIOP PHASF WAIFINAWINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12 7 �� <br /> 7 <br />` L[, 1/78 2M <br />