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SAN JUAQUIU UUUAJ- HLAL I N UiS I KIL I <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued. /3-7 <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 /> ,:oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS /-5-2,Z3 r CITY/TOWN <br /> Owner's Name ea. Phoneisl -6091;2-/ <br /> Address City <br /> Contractor' s Name Licensedi�rd -� Phones V 2 <br /> 'S CCRTIFICATE OFJORKfiiAfiJ'$ CO"iPENSATIO'i I'JSURAfiJCE ONFILE WITHSJLHD? YES 4,-' NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TA K SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack f. Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformationRfz <br /> Geophysical Surface..Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> - � � �� H.P. <br /> Type of Pump � _ / T ^ <br /> PUMP REPLACEMENT: r]State Work Done f.. <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 accordancf <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 G OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: —.24- <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE�� <br />_EH 1426 Rev. 12-77 01./78 2M—' <br />