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'SAN JOAQU1N„LUUAL KtAL1N. 1115IKlUI Permit No. j <br /> FOB OFFICE USE: ,/1601 E. Hazelton„Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1. Year From Date Issued <br /> Complete In Triplicate <br /> Application. is hereby made totheSan Joaquin Local Health District for a permit to construct <br /> and/or install the work•herein described RTles apolReaulat;ionsti:on is modfethe San in pJoaquin wLocal ith aHealth <br /> oac�.,3 n County Ordinance ,o. 1862 and theu 9 i <br /> ulistr�ct. <br /> �.� CITY/TOW N <br /> EXACT STREET ADORES 5 �� <br /> Phone <br /> Owner' s Name 7- � <br /> Address <br /> Contractor's Na a <br /> Licens Phone <br /> _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI YN It1SURANCE OP1 FILE WWITH5JLHD? YES I,O� <br /> , <br /> TYPF__OF WORK (Check) : - NEW -.WELL❑ . DEEPEN ❑ RECONDITION ❑ _DESTRUCTION.❑OTHER - -- - -- f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT MP REPLACEMENTt�/► <br /> PUMP INSTALLATION L��PUMP, REPAIR❑ P <br /> K SEWER LINES' PIT PRIVY <br /> DISTANCE. TO NEAREST: SEPTIC TAN p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> j PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �mestic/private Drilled Dia. of Well Casing of <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 Se 1 ,Insta led b : <br /> ,. <br /> PUMP INSTALLATION: Contractor. L� '� '` H,P. <br /> Type of P Cl” <br /> , PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Materia and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will -be done in accordanc <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 lifornia. ” <br /> II WILL CAL OR A GR T INSPE 0, P TO GROUTING AND NAL INSPECTION. T <br /> SIGNED TITLE: DAT <br /> L T PL N ON REV SIDE <br /> FOR DEPARTM T USE ONLY _. <br /> PHASE I DATE <br /> ;APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE' II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION 'BY DATEJ Q <br /> 1/7.8 2M. <br />