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SAM JUAQUIN LUL:AL HtAL1H U151k1L1 m <br /> FOB OFFICE USE: "` "1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. YLj� <br /> Telephone C'-(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> rq `) This Permit Expires I 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. p� <br /> EXACT STREET ADDRESS ` S C CITY/TOWN <br /> Owner's Name M Phone <br /> Address City <br /> Contractor's Name - License# cId /8 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO" 'i-NSURAMCE ON FILE WITH SJLHD? YES L NO <br /> TYPE OF WORK (Check) : NEW WELL' qN1 DEEPEN 0 RECONDITION ❑ DESTRUCTION[j � <br /> WELL CHL RINATION ❑ WELL ABANDONMENT p_OT}SER 0_ � <br /> PUMP INSTALLATION C] PUMP REPAIR❑ PUMP REPLACEMENT Q -�71 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI TMS <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 �� ary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑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 , Regulations of the Sari Joaquin Local <br /> Health District. Home owner or licensed agent' signature cer 'fies the following: <br /> "I certify that in the performance of the wo k for which this permit is issued, I shall <br /> not employ any person in 'such manner as to b ome subject t W kman's Compensation <br /> laws of Caiiforni ." " <br /> I WILL CALL FOR GR T INSPECTION P O TO GROUTING A AL NSP <br /> SIGNED TITLE• - DATE: IT <br /> C <br /> PLOT PLAN ON SE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -���' INSPECTION 8Y DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />