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ter. .�.. <br /> -�---- MN JUAQUI N LUUAL MtAL I M U15 ! ttlL i <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.:1-10"7i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Conipl ete 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 /> ,oanuin County Crd-inance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> EXACT STREET ADDRE � 'y a �, -d CITY/T N , y_, <br /> Owner's Name ,Z Phone <br /> Address City _La <br /> Contractor' s Na Z- J Jk4W-CLicensQN;R6y Phone <br /> IS CERTIFICATE OF WORKMAN'S C0114PENSATIOIN IPJSURANCE ON FILE WITH SJLHD? YES IN � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION(:] �- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ N <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER F <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLTN <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />_�mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical urfac92§eal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: { ❑State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> Describe Material an 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 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 o alifornia. " <br /> I WILL CA FORA ROUT NSPE I � PRIO TO GROUTING AND A NAL INSPECTION. <br /> SIGNED TITLE: DAT 1 <br /> (DRA LOT PLT-N- ON REV DE <br /> FOR, DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /�� , .---- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY !!!�7 DATE 7� <br /> EH 1426_____ _Rev_. 12-77 1/78 2M <br />