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r <br /> {- JAN JUAQUIN LUUAL MtHL I M Ul,J I Kl U I <br /> � <br /> FOR OFFICE USE: 1601 E. Hazelton -Ave. , Stockton, CA 95205 Permit No. - s- <br /> Telephone; (209) 4.6.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -7 <br /> Th�.is Permit .Ex ire's 1 Year From' Date Issued <br /> *.; Complete' In' Tri pl i tate <br /> Anplication 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 />� �oaquin CountoOrdinance No. 1862 and the Rules 'and Regulations of the San Joaquin- Local Health <br /> District. - S <br /> EXACT STREET ADD SS Q - CITY/TOWN S <br /> Owner's Name <br /> Phone <br /> Address' .-. City <br /> Contractor' s Name License# oS3- PhoneT_3, 'L_-!;*'�_3 <br /> T. S CERTTFICATE OF WORK?IAN'S &MPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN El RECONDITION, [] DESTRUCTION C ] <br /> WELL CHLORINATION 0 WELL ABANDONMENT Cl OTHER 0 <br /> PUMP INSTALLATION Cq PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTICJANK SEWER LINES PIT PRIVY ; <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL tPUBLIC DOMESTIC WELL <br /> INTENDED USE ( TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industri aT ­7—Drilled <br /> �- Cab1e--Toole -_- -- Dia, of Well Excavation <br /> �X_Domestic/private 7 Drilled Dia. of Well CasingY <br /> Domestic/public Driven 1Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodi c Protection ,Rotary- .--,--- - :Type of Grout <br /> Disposal 'Other" �'` 'Other Information <br />! Geophysical Surface Seal In by: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P. i <br /> PUMP REPLACEMENT: Q State Work Done ' <br />' PUMP REPAIR:_ ❑State Work Done <br /> DESTRUCTION .OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .F <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 em l.o <br /> p y any person in such manner as to become subject to Workman's Compensation <br /> laws of California.. " <br /> I WILL CALL. fa A ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> S.IGNE I TITLE: � DATE: �Z-?' <br /> I DR W PL T PL N ON REVERSE SIDE <br /> PHASE i <br /> F R DEPA TMENT USE ONLY <br /> '�� � , <br /> APPLICATION 'ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ,PHASE III FINAL INSPE TION <br /> INSPECTION BY DATE INSPECTION°`BY 1a DATE S=2-7� <br />,EH 1426 Rev. 12-77 1 /4P 0V <br />