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JAN JUAQUlN LULAL HtALIH UlJIKIUI <br /> FOR OFFICE USE: /l 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. �& <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -�— ; <br /> This Permit Expires 1 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 />,oanuin County Ordinance 1o. 1862 and the Rules andRegulationsof the. San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �� Gam, G, �'�� CITY/TOWN <br /> Owner's Name0 Z�, Phoner� <br /> Address / f ' _cr�. .Lt.� Ci ty7 � - -z -r — <br /> Contractor's Name. pe,; r--1 - _ ' L i c e n s PhoneL I ,J-f <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURA"!CE ON FILE WITH SJLHD? YES -- NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIRW PUMP REPLACEMENT ❑ C7- <br /> DISTANCE <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven - Gauge of Casing_ <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 <br /> Type of Pump —H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> s .• r'�. <br /> PUMP REPAIR: [R tate Work Don � <br /> DESTRUCTION OF WELL: Well Diameter ff 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." A <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: � b DATE: -3- s79 <br /> DR W PLOT PL N ON REVERSE SIDE <br /> PHASE I <br /> FOR DE ENT USE ONLY <br /> —� <br /> �2 <br /> ��JZ7 <br /> 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> EH 1426 Rev. 12-77 1/78 2M <br />