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)AN JUAI�tSIN .LMAL htALIh U1,>tKILI Permit No. �Jr� <br /> NFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: {209) X66-6781 Date Issued Ll <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit : . fres 1 Year From Date Issued <br /> Compl ete I n .Tri p1 i cate t; - <br /> b made to the San Joaquin Local Health District for a permit toconstrlJ'ct <br /> Application is here y <br /> Regulations of the San Joaquin Local Health <br /> and/or install the work herein described,. This application is made in compliance wit an. <br /> ,,can-Jin County Ordinance No. <br /> . ]862 and the Rules a 9 <br /> District. ��f � �'-} CITY/TOWNA � <br /> EXACT STREET ADDR SS 2 J <br /> ��� '��s Phone <br /> Owner's Name �- t City <br /> AddressLi cense <br /> Phone �'/ <br /> 4Contractor"s Name <br /> #F/. <br /> Kfi1Afid'S COfi4PENSATIO"1 INSURR?.1C£ Ofi� FILE WITH SJLHD? YES NO-------�— <br /> IS CERTIFICATE OF WOR w _ --- <br /> _ - -- �-` DESTRUCTION❑ <br />' TYPE OF WORK (Check) : NEW WELL❑ <br /> WELL CHLORINATION DPEN C1 ❑ WELLEASANDONM£NT��OTHER 0 <br /> PULP INSTALLATION [3PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> y SEWAGE DISPOSAL FIELD`. CESSPOOL/SEEPAGE PIS OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL -- — PUBLiC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab <br /> INTENDED USE le Tool Dia. of Well—Excavation <br /> Domestic/private Drilled € Dia. of Well Casing <br /> Domestic/public Driven - - Gauge of Casing <br /> Irrigation 7 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor ° <br /> Type of Pump H.P. <br /> 1PUMP- REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: _ ❑State .Work Don _ <br /> r - - App rox�mte D pth�>y / - <br /> DESTRUCTION OF WELL: Well Diameter 1 i ►� j�S, <br /> escribe Materia and Prioce re I <br /> II hereby certify that I have prepared this application and that the work will be done in accordan <br /> . with San Joaquin County Ordinances , State taws, and Rules -and Regulations of the San Joaquin Loca <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 California." <br /> II WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE: � �DATE: <br /> DRAW PLOT PL N ON REVER E SIDE <br /> FORD 'RTMENT USE ONLY <br /> PHASE I - - DATE <br /> iKPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY� DATE INSPECTION BY <br /> ru 1A )C Dim 19_77 - - <br />