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- J1 SAN JOAQUIN LU(:AL -HLAL I H UIS I KIU I � A <br /> TOR FFICE USE: 1601 E. Hazelton Ave.- , ,Stockton, CA 95205. <br /> Permit No. r <br /> Telephone: (209) 466-6781 %;1-QUC <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ices 1 Year from Date Issued <br /> Complete In Trip icate ' <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, }1862aand the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �Q CITY/TOWN,�� jS'.74! <br /> Owner's Name <br /> Phone_2�/--©�U t <br /> Address - citys <br /> License# Phone �y►j-1�1Q ' <br /> Contractor's Name - <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL II DEEPEN [] RECONDITION Q DESTRUCTIONE2 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER Q CA <br /> PUMP INSTALLATION [] PUMP REPAIR Q PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANS- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOL/SEEPAGE PIT OTHER <br /> r <br /> PROPERTY LINW4PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL — ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> {{{JJJ ' <br /> Domestic/private Drilled Dia. of Wel l}Casing �� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal : 4 <br /> Cathodic Protection , Rotary Type of Grout £ <br /> Disposal 'Other �` � , `Other Information <br /> GeophysicalSurface Seal Instal e <br /> PUMP INSTALLATION: Contractor ~ <br /> Type of Pump : <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done 1 <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 Cal ifornia:-"� . .. <br /> I WILL CALL FOR A OUT APMOe IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br />'f <br /> W PLT L N ON REVERS IDE - <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> - <br /> APPLICATION ACCEPTED BY . 'DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE . E GROUT INSPECTION PH E III FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE lb- l - 2S <br /> 1/78 2M <br /> f EH 1426 Rev 12-77 <br />