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*F. AN JUAQUIN LULAL HtALIM U1�)IKIUI <br /> 1601 E. Hazelton Ave. , <br /> FFICE USE: Stockton, CA 95205 Permit No, �� <br /> -� <br /> Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires Date Issued <br /> Complete I n Tri pl i.cate <br /> - i <br /> Application is hereby made to the .San Jaquin aDistmade infor <br /> compliancetwithnSanuct <br /> and/or install the work herein described.. This -application <br /> the Rules and- Regulations of the San. Joaquin Local Health <br /> Joaquin County Ordinance No.1.1862 an.d <br /> District. <br /> . CITY/TOWN <br /> k EXACT STREET ADDRESS Phone — �- <br /> Owner's Name <br /> st City_ <br /> Address Phone <br /> k <br /> Contractor's Name ._ Mare 1 l,/1E License# <br /> I5 CERTIFICATE 'OF WORKfi1AN`S`ICOMPENSATION INSURAINCEON FILE WITH NO <br /> SJLHD? YES <br /> TYPE OF WORK (Check) : NEW i�ELL�Y x DEEPEN 0 ' RECONDITION�Q . --�DESTRUCTI.ONQ <br /> W <br /> WELL{ CHLORINATI-ON 0 - WEL-.L ABANDONMENT Q-- OTHER-0 ao <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT Q ` c� <br /> DISTANCE TO NEAREST: SEPTIC TAN d1f SEWER LINES PIT PRIVY — <br /> SEWAGE DISPOSAL FIELD CESSPGOL/SEEPAGE PIT -- OTHER <br /> PROPERTY LINFldI#PRIVATE DOMESTIC WELL P— PUBLIC DOMESTIC WELL --- <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE << <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ��Domestic/private Drilled � . Dia. of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation . =Gravel Pack Depth of-Grout Sea <br /> Cathodic Protection -�otary Type of Grout <br /> Disposal Other_ -Other-Irrformation <br /> Geophysical Surface Seal Instal ed b <br /> f PUMP INSTALLATION: Contractor -" <br /> k Type` of Pump H' ' <br /> PUMP REPLACEMENT: p State Work Done T y <br /> PUMP REPAIR: CIState Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Materia n Prodre� �" ., 46 7-2 5, <br /> f //f141.6 <br /> 'f. that d have regar this application and that� the work ill 6e done in accordar <br /> I hereby certify <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations' of the San Joaquin Loci <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 subj c�t. to Workman's Compensation <br /> laws of California." <br /> I WILL CAL FOR A GR T INS CT P I TO GROUTING AND A FINAL INSPECTION. <br /> :SIGNED TITLE: Z_ DATE: <br /> D L T L N ON REVERSERL SIDE <br /> FOR DEPART M :NT USE ONLY <br /> PHASE I �� DATE_'' r <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III INAL INSPECTION <br /> PHASE II ROUT NSPECTION DATE G <br /> INSPECTION BY PATE -3� _ INSPECTION BY_ GI/ <br /> f /78 21 <br /> k ru 1 nati Daw 19_77 - <br />