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__ AN Q IN LOCAL HEALTH DISTRICT <br /> F "SCE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Nog^ <br /> �' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <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 /> .'oaq,jin County Ordinance, No. 1862nd the Rules and Regulations of the San Joaquin Local Health <br /> District. At.., G/• � :..YC3-_, 1,50- 24' 9 <br /> EXACT STREET ADDRESde <br /> S _= _ _ _ CITY/TOWN <br /> Owner' s NamePhone <br /> Address - A O O 6 City_ e_'-'Z11 <br /> Contractor's Name �- License# ), `Phone <br /> IS CERTIFICATE OF WORKMAN'S C NSATIO" INSUR,4ANCE ON FILE WITH SJLHD? YES NO ' <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN ❑ M1 wRECON`DITION C3 DESTRUCTION E3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION,,(, . PUMP-REPAIR El PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER- LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Z <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tooli; Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> —Domes-t-is/publ i c Driven 1�1 Gauge of Casing - - —�' <br /> i <br /> _Irr-igatonf Gravel Packl Depth of Grout Seal <br /> Cathodic Protection Rotary b Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Installed by: <br /> i <br /> PUMP—rNSTA-LL-ATiON• -�Contrac or <br /> . T- -` <br /> Type of Pump w _ T H <br /> PUMP REPLACEMENT: [] State Work Done j <br /> PUMP : (State Work Done ►vf�,� __ ;� , a� a � 0 AZ. — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I ve prepared this application and that the work will be done in accordance <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. ....1.R4 <br /> I <br /> I WILL CALL FOR A GROUT INSPE ON PR4-a TO GROUTING AND A FINAL INSPECTION'. ' 1 <br /> SIGNS TITLE: �- DATE: 1 <br /> Z�DRAW PLOT PL -ON REVERSE SIDE i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f : DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION , ;e1PHASIAI <br /> -FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION B DATE <br />