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iHIV JUHQU1N LUCAL HtHLIH U1J1K16 ' <br /> F ICE USE: 1601 E. Hazelton Ave.,, Stockton, CA 95205 Permit No.—$- Ib� <br /> j 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 Trip icate _ <br /> Application is hereby made to the San Joaquin °Local -.Heap-h District for .a permit to construct <br /> and/or Lins-taII -the work herein described. This applioa:tion is .made in compliance with.San <br /> ��l�t <br /> Coaqu i n' County -Ord i nance- No.' 1862 and -the. Rules and Regul ati-ons of the- San.Joaquin . a jh <br /> District. �f` 70 Ow �/ � <br /> EXACT STREET ADDRESS . ilrlo CITY/TOW <br /> Owner's. Name Phone <br /> Address 0..62 City. <br /> Contractor's Name i;� License# Phone <br /> 'S CCRTTrICATE OF WORKHAN'S 'COMPENSATION P1SURA'•IC£ ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> - v <br /> WELL CHLORINATION WELL ABANDONMENT p OTHER M <br /> PUMP INSTALLATION PUMP REPAIR Q PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> PROPERTY LINE --PRIVATE DOMESTICWELL ^ E �� OTHER <br /> SEWAGt DISP S L FIELD CESSPOOL/SEEPAG <br /> . � � � � PUBLIC DOMESTIC WELL <br /> INTENDED USE `. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Cable Tool Dia. of Well Excavation <br /> Domestic/pr.ivate Drilled Diva. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary . Type of Grout <br /> j Disposal Other Other Information <br /> ! Geophysical Surface Seal Instaa by: s <br /> PUMP INSTALLATION: Contractor awlwlog� a <br /> j Type 16 Pump e.,Ozx� H, <br /> PUMP REPLACEMENT: p state Work Done_ - w <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well ;Diameter '�� Approximate Depth <br /> Describe Material and Procedure <br /> w <br /> I hereby certify that I have' <br /> .1 this fappiication. and that the work will be done' in accordance <br /> with San Joaquin County Ordinances, State' Laws; and kules and Regulations of the Sari Joaquin Local <br /> Health District. Nome ownerlor licensed►agent's signature certifies the following: ; <br /> "I certify that in the performance of thew ark •for- which this permit is issued, I shal l <br /> not employ any person in'such manne►as to-become subject to Workman's Compensation <br /> laws of California." 1. -1 4��� <br /> I WILL CALL FOR A� GROUT INSPECTION PRIOR TO GROUTING AND .A-FINAL INSPECTION. <br /> SIGNED I TITLE: '" - DAT1~:" <br /> (DRAW PL T PLVN ON REVERSE SIDE <br /> PHASE I V , FPR DEPARTMENTUSE ONLY <br /> APPLICATION ACCEPTED BY I. DATE ^��/1�-7r__- <br /> ADDITIONAL COMMENTS: # <br /> PHASE II GROUT INSPECTI N PHASEJ I FIN6L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE_ _ 3-4 -- <br /> r EH 1426'' Rev. 12-77 • . , - _. .1 2M <br />