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JAN JUAQUIN LUUAL HtALlH Ulf1KILI <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit FNo. -9r—/1�S-� <br /> Telephone: (209) .466-6781 <br />�--� � APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> 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 /> k2oanuin County ordinance %.0.. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 2W ..5'641 IV" CITY/1`Mr <br /> Owner's Name y d Phone <br /> Address City <br /> Contractor's Name License#2-&'7R,6 Phone VV-52,1. 0 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES A-00, NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN p RECONDITION [] DESTRUCTION[D <br /> WELL CHL RINATION C3 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 4 PUMP REPAIR 0 PUMP REPLACEMENT 0 � <br /> DISTANCE TO NEAREST: SEPTIC TANKITO �-SEWER LINES S­0 {—PIT PRIVY -- <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT p Q OTHER �—' <br /> PROPERTY LINE1 �'PRIVATE DOMESTIC WELL1 s_ PUBLIC DOMESTIC WELL ., <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Kt <br /> omestic/private A--Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 40 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed _by: <br /> PUMP INSTALLATION: Contractor 490 <br /> Type of Pump H.P, <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 <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 employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR AGWU.TINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE:*46e4op <br /> R W PLOT PL N REVERSE SIDE <br /> PHASE I FOR DEPARTMEN USE O LY <br /> APPLICATION ACCEPTED BY DATE e11104-- 7S <br /> ADDITIONAL COMMENTS: <br /> P SE I SPECTIO1 PHASE II FI L IN PECTION <br /> INSPECTION BY DATE q INSPECTION BY ATE 5 2 <br /> EH 1426 Rev. 12-77 �� �d 1 /78 2M <br />