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f <br /> b 5AN JUAQUIN LUUAL HLAL I H U1J 1 KD,1 <br /> r FSE: 1601 E. Hazelton Ave.,, .Stockton, CA 95205 Permit No.--)%- I0$'a- <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 - Heal-th District for a permit to construct <br /> and/or install -the work herein described. This application ,is .made in compliance with..San <br /> ,oaquin County -Ordinance No.' 1862 and the, Rules and Regulations of the San Joaquin ��ppca�� l / <br /> h <br /> 'district. � �jjplG 70 4Gt/N'�L� 7) <br /> EXACT STREET ADDRESS CITY/TOW <br /> Owner's Name Phone <br /> Address 0 6 . t�J . City. <br /> Contractor' s Name License# Phone <br /> '.S CERTIFICATE OF WORKMAN'S 'COMPENSATI0"1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONE3 o <br /> WELL `CHLORINATION WELL ABANDONMENT ED OTHER ❑ <br /> PUMP ,�NSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGt 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 ICable Tool Dia. of Well Excavation <br /> Domestic/private 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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> a <br /> j Type iof Pump e2Ji H.P. <br /> f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well ;Diameter Approximate Depth. `. <br /> r Describe Material and P,roce ure <br /> k I hereby certify that I havelprepared 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 ownerlor licensed agent' s signature certifies the following " <br /> "I certify that in the performance of the'-work for which this permit is issued, 15hall <br /> not employ any person in °such manner as to4become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A'FI.NAL INSPECTION.' <br /> 4 SIGNED C TITLE: " DAT)r "' <br /> t <br /> (DRAW PL T PL N ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED {� -- <br /> C£ TED i3Y DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTI N PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE_Aj INSPECTION BY DATE <br /> EH 1426 Rev_ 12-77 a _, ...1 2M <br />