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SAN JOAQUIN LOCAL, IN U151flil:l � <br /> CA 95205 _: Permit No. 8'. <br /> FQR FFI'CF USE: 1601 E. Hazelton 'Ave.; ,tockton, 1 <br /> a Telephone:`` (Q9) 466-6781 Date Issued <br /> L APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit -Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> A lication is hereby made to the San Joaquin Local Health District for a permit to-construct <br /> pp application is made in compliance with San <br /> and/or install the work,herein. described. This <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health <br /> District. f� <br /> EXACT STREET ADDRESS X. �'�� � .• CITY/TOWN -5 <br /> c� <br /> Phone '015-t— 2,S3 <br /> Owner's Names <br /> City_ ���'. .�-. <br /> Address �'� � � �� ..� �.� - <br /> �Liense#� f 6 Phone <br /> Contractor's Name <br /> IIS CERTIFICATE OF WORKMAN'S CO"1PENSATIO'N i'1SURAINCE ON FILE WITH 5JLND? YES N0 <br /> .TYPE OF WORK (Check) : NEW WELL UR DEEPEN Q RECONDITION 0 DESTRUCTIONE2 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHERT <br /> PUMP INSTALLATION Z1 PUMP_REPAIR Q PUMP REPLACEMENT Cl , <br /> DISTANCE TO NEAREST: SEPTIC TANK � O SEWER LINES QL/SEEPAGEPIT YPIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL 2 " PUBLTC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL' CONSTRUCTION SPECIFICATIONS <br /> �m =Industrial Cable Tool -Dia.�Yof Well Excavation_ to `F <br /> �- Domestic/private <br /> Drilled k Dia.. 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 /> Other Other Information <br /> Disposal Surface Seal Instal ed b <br /> GeophysicalVo <br /> �; R <br /> PUMP INSTALLATION• Contractor <br /> Type of Pump �..� t H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState Work Done ry--� _,� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Proce ure <br /> I hereby certify that I have prepared--this- application and that the work will be done in accordam <br /> I with San' Joaquin County .Ordinances , State Laws, and Rules and Regulations of the -San Joaquin Loca' <br /> Health District. Home owner or Licensed agent's signature certifies the following: <br /> hall <br /> "I certify that in the performance of the worktfor which this permit is issued, I s <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ` r <br /> SIGNED �� <br /> TITLE: DATE: "��l �t <br /> DR W PLOT L N ON :REVERSE !SI�DE�� <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I DATE 67--' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II FINAL INSPECTION <br /> PHAE II RO T INSPECTI N PATE <br /> INSPECTION BY , ` ATE 1. <br /> INSPECTION BY <br /> IPO <br /> 1.178 2N <br /> _ - <br />