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. .� SAN JOAQUIN LOCAL' HEALTH DISTRICT -- <br /> F CE USE: 1601 E Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 456y-57DI <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date 'ISmed -tea <br /> (Complete In Triplicated <br /> Application is hereby made to the San Joaquin Local Health District for a'permit to construct <br /> and/or install the work herein described. This application is madeincompliance with San <br /> Joaquin County Ordinance No 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District, y <br /> EXACT STREET ADDR (S' <br /> L- CITY/Toll-2E <br /> Owner's Name <br /> .Phone <br /> Address = <br /> Ci ty, <br /> Contractor's N e x <br /> License � hone 'Z — <br /> I CELT IFTCATE OF MRlfttA S 'COMPENSATIWINSURANCE ON FILE WITH-SJLHD? Y <br /> TYPEOFWRK (Check): NEW-WELLL DEEPEN ,RECONDITIONz ERUCTIQf0-- <br /> WELI. CHLORINATIt3N ABANDONMENT0 OTHER <br /> PUMPINSTALLATION PUMP REPAIRS ;PUMP REPLACEMENT` <br /> RISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD. CES L/SEEPAGE PIT �'IDTHER <br /> PROPERTY LINE - PRIVATrWESTIC WELL--— PUBL=UTIC W <br /> INTENDED USE 4 TYPE OF-WELL., CONSTRUCTION SPECIFICAT,I, NSS <br /> Indust��a1_'.. <br /> Cable To Dia. of We xcavat,on <br /> mestic/private Drilled Dia of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graveli-pack Depth" of®Groin''+ ea <br /> Cathodic Protection Rotary �T .6out <br /> _Disposal _ .�.. yPe aai ...�..._._. <br /> eophysical Df ,. <br /> .e <br /> Surface Seal I e :. <br /> f'UMP. INSTALLATION: Contracto <br /> T <br /> Vie,of, P <br /> H.P. , <br /> PUMP REPLACEMENT: ' . <br /> (State Work Done . <br /> PUMP REPAIR: -` QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth , <<_ <br /> Describe Materlal Mater-laand Procedure T <br /> I hereby certify that I hare--preP red this application and that the work will be none in ac ' <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joagatr10 l `' <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 /> notempl any person in such manner as to become subject to Workman's Compens tion, <br /> laws o alifornia. ` <br /> I WILL OR A GR UT INSPECTOK P IOR 767GROUTING AND NAL INSPECTION. <br /> l <br /> SIGNED J'1- ov <br /> } <br /> TITLE• DATE: ... <br /> ON RE ; <br /> FOR DEPARTNE USE <br /> PHASE I ------ <br /> AI' TION ACCEPTED BY DATE 41 P � <br /> AbDITIONAL COMMENTS: <br /> PHASE I ILPECTION <br /> INSPECTION BYPHASE III FINAL INSPECTIOW <br /> DATE INSPECTION BY- -a. DATE <br /> EN 14 26 Rev. 9/78 <br />