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SAN JUAQUIN LULAL HLAL•I H UJ!5 I K1C. f—FOR k <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No• R- 14 <br /> Telepfhone: (209). 466-6781 <br /> 1.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a),8- ; <br /> This Permit -Exp ires 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 J <br />,'oaquin County Ordinance FSU. 1862 and the Rules and Regulations of the San Joaquin Local Health 1 <br /> District. <br /> �/ <br /> EXACT STREET ADDRESS ry �` CITY/T-fflmtL <br /> Owner' s Name i` < Phone <br /> Address City _ <br /> Contractor' s Name d7 LicensePhone { ���� �« _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"I I"dSU 10E nN FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN G RECONDITION DESTRUCTI,ON[ <br /> WELL CHLORINATION 0 WELL ABANDONMENTj�� OTHER 0 <br /> PUMP INSTALLATION S UMP REPAIR❑ PUMP'.REPLACEMENT ® <br /> DISTANCE TO NEAREST: SEPTIC TANK_ OfJ�EWER LINES��IT PRIVY" <br /> SEWAGE DISPOSAL-FIELD CESSPOOL[SEEPAGE PIT OTHER (,J <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 /> Frilled Dia. of Well Casing <br /> _omestic/private Domestic/public Driven z Gauge of Casing Z 16A9 jolelle". <br /> Irrigation Gravel Rack Depth ,of.. Grout-Se.a.l <br /> Cathodic Protection Z--'Rota ry Type df Grout F <br /> Disposal Other Other Information <br /> Geophysical Surface 'Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump d' t H.-P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter �` - Approximate Depth <br /> Describe Materind Pro duce <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'us`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 A GROU INSPECTION PRIOR TO GROUTING AND A-F. NAL INSPECTION. <br /> SIGNED TLE: p ' DATE: 7ser <br /> DRAW PLOT PL N ON VER ;SIDE <br /> FOR DEPARTMENT USE- ONLY <br />'PHASE i - -` DATE 27 <br />;APPLICATI.ON ACCEPTED BY Oil <br />'ADDITIONAL'�COMMENTS: <br /> PHAS II GROUT INSPECTION PHAS" I I FINAL INSPECTION <br />;INSPECTION BY DATE l$__ INSPECTION BY I 1= DATE b- -`I <br /> H ,.}rev_ 1_2=77 ��: r 1 78 <br /> . , R arses_ - 6°'+r <br />