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- . bAN JUAQUiN LUGAL HtAL{h UiJ I KiL! ; <br /> ICE USE: 1601 E. Hazelton Ave.,, Stockton, CA 95205 Permit-No.7�- <br /> Telephone; " (209.) 46.6-6781 Date Issued d s 7� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires Year From Date 'Is'su'ed <br /> Complete In Triplicate <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 made in compliance with San i <br /> ,'oanuzn County Ordinance•-141o. 1862 and the Rules and Regulations of the San Joaquin. Local Health <br />' District. <br /> --"S_ . � lGl/� � CITY/TOWNR17 <br /> EXACT STREET ADDRESS ' <br /> Phone <br />: Owner' s Name <br />' <br /> Address ; S � City <br /> Contractor's Name :y' d �°5, .5 Li cense r' Ur Phone <br /> IS CERTIFICATE OF WORKr1AN'S_CMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Che fkf: NEW WELL + DEEPEN ❑" RECONDITION Q DESTRUCTION( - W <br /> r.! WEL-L­-C-H.L-OR-I-NATION-•9­ - WELL ABANDONMENT 0 OTHER 0 <br /> y' PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> c� fi SEWER LINES) PIT PRIVY <br /> DISTANCE TO NEAREST: -SEPTIC. TANK_ D - <br /> SEWAGT DISPOSAL MELD CESSPOOL/S EP9GE PIT�-/OTHER <br /> + �PROPERTY LIN /0-70RIVATE DOMESTIC WELE�—L PUBLIC DOMESTIC WELL <br /> k z - <br /> INTENDED USE TYPE OFfWELL CONSTRUCTION SPECIFICATIONS <br /> ndust'ria - Cable-Tool Dia. of Well Excavation - <br /> 1. <br /> —�omestic/privAe- ��ri1- ed Dia. of Well Casing <br /> Domestic/public Rriyen _ - Gauge of Casing <br /> Irrigation �, Grave%Pack Depth of Grout Seal 6 <br /> Cathode c Protection /./Rotary w , , Type of Grout <br /> Disposal F- Other ;Other_"'Informati on <br /> Geophysical 'j * *° , " Surface Seal _Instal . ed,.b <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpAdz <br /> ��'�` <br /> _. ... - �- <br /> f PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR:r" ❑State Work Done <br /> [DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and cedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 California." <br /> I WILL CALL FOR A T INSP CTION PRIOR TO GROUTING AND A F NAL INSPECTION. <br /> ,SIGNED TLE: SI DATE: <br /> RAW PLOT PLAN 0 REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ,ADDITIONAL COMMENTS . <br /> PHASE II INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION Bb DATE ,. INSPECTION BY DATE <br /> zN ra0� PpU_ 17_'77 1/78 2t - <br />