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SAN JUAQU1N LUUAL HtALIH UISIKILI <br /> FOR OFFZE:E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> IV Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT f <br /> This Permit Expires 1 Year From Date Issued R k <br /> Complete In Triplicate) Ta <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS,;?!J-16— CITY/TOWN di <br /> Phone <br /> Owner's Name ��.5�=1 <br /> Address City <br />_Contractor's Name License Phone) <br /> IS CERTIFICATE OF WORKMAN'S COM PENSATInm INSU A"ICE ON FILE WITH SJLHD? YES NO w' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION ❑ DESTRUCTION❑ 4 . <br /> WELL CHLORINATION El <br /> Q WELL ABANDONMENT 0. -OTHER El <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT 0 NZ <br /> DISTANCE TO NEAREST: SEPTIC TAN t \SEWER 'LINES PIT PRIVY <br /> SEWAGE DISP S FIELD CESSP.00L/SEEPAGE PIT OTHER r' <br /> PROPERTY LIN VtO-. PRIVATE DOMESTIC WEL - PUBLIC DOMESTIC WELL -- . <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial f Cable Tool Dia. of Wel Excavation «. �u <br /> Domestic/private f Drilled . Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation ; Gravel Pack Depth of Grout Sea ? <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> CIL- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: a State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Ma-terial ana 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 C FOR A GROUT YNSPZTNVARIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: Jigk DATE: <br /> R W PL PL N ON REVS S SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ 92% <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION.. PHASE I I ICAL. INSPECTION <br />' INSPECTION BY DATE INSPECTION BY HATE / 17X <br /> rig � e.✓F n 11 � T . . _11 1 /78 2M <br />