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FFICE USE: SAN J�JK[�uIN L�i;HL F�tHL!H ui5I RIC l <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 ~ S� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued � <br /> This Permit Expires 1 Year From Date Issued z. } <br /> u9mPl ete In Tri p1 i cafe <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit to constructand or install thwork <br /> 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 aquin Local Health <br /> EXACT STREET ADDRESS <br /> Owner's Name CITY/TOWN <br /> Address Phone <br /> Contractor's NameCity. ' <br /> License#klo Phone ,�� -- <br /> IS CERTIFICATE OF WORKP1Am'S CO�1PENSATIO.I It'�SURA" <br /> !CE ON FILE WITH SJLHO? YES. 4--­N0 <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN ❑ RECONDITION C3 DESTRUCTION C3 <br /> --- <br /> WELL CHLORINATION <br /> 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL [ <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of We11 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing �- <br /> Gravel Pack Depth of- Grout-Seal <br /> Cathodic Protection Rotary T <br />____� Disposal Other Type of Grout <br /> Geophysical Other information <br /> - <br /> PUMP INSTALLATION: Con tracto <br /> Surface Seal Intailed by: <br /> Type of Pump <br /> PUMP" REPLACEMENT: MMState Work Don H.R: <br /> cUMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and Procedure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> O th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin LocalA <br /> lealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the <br /> not employ an Performance of the work for which this permit is issued, I shall <br /> p y y person in such manner as to become subject to Workman 's Compensation <br /> laws of California. " <br /> WILL CALL FORA G T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> LIGNED TITLE: <br /> DRAW PL T PL N DATE: <br /> ON REVERSE SIDE <br />-LASE I FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE_ =66 7 <br /> PHASE II GRPOUT ION PHASE 1INA1 INSPECTION <br /> ISPECTION BY DATE <br /> INSPECTION BY DATE <br />! 1426 °. _Rev "ti1r77- <br />