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SAN JUAQUI N LULAL.. ,MEAL 1 M UlJ I KI L I <br />-EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-Z�,_) ,Y X <br /> Telephone: (209) 466-6781 '� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete . In Triplicate <br /> Application is herebymade to the San Joaquin Local Health District for permitconstruct <br /> q ap to <br /> and/or install the work herein described. This; application .is made in- compliance with San { <br /> Joaquin County. Ordinance No- 1.862 and the Rules and Regulations of the San -Joaquin ,Loca.l Health <br /> Dstrict. <br /> EXACT STREET m <br /> �' CITY/TOWN <br /> Owner's Name <br /> Phone $2S <br /> Addrpss, 0 LAJ City . <br /> Contractor's Name License# Phone <br />_'S CCRTiF"ICATE OF 1JOI2K4rJ'S COMPENSATI0N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION 0 WELL ABANDONMENT ED OTHER 0 � <br /> PUMP INSTALLATION DQ PUMP REPAIR❑ PUMP REPLACEMENT [� <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 tfpc OF WELL CONSTRUCTI'ON-SPECI-FICATiONS-�- <br /> Industrial Cable Tool Dia. of Well Excavatiori,.,�.." ' ` <br />-- —Domestic/private , Drilled Dia, of Well. Casi-ng , k <br /> Domestic/public :T—Driven ;,Gauge of Casing <br /> Irrigation s�- Gravel Pack � Depth of Group-.-Sea <br /> Cathodic Protection 't " _ Rotary . , Type of Grout ^� <br /> Disposal i; Other ,.. t. Other Information <br /> Geophysical �� Surface Seal ' I'nstal ed b <br /> PUMP INSTALLATION: Con tractor_4==Zr-�J,9 <br /> Type of PumpH.P. <br /> -- <br /> PUMP REPLACEMENT: S_tate_Work_Done <br /> PUMP-REPAIR-: >,�n�. "OState Work Done .; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure �- - - --� <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locals <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 C R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIG TITLE: DATE: ,-1 — --72 i <br /> ,i (DRAW PLUT PENN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BYQP. DATES <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III F 'NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3- ?y <br />:H 1426 Rev- 12-77 -" 1 -j-7S 9W <br />