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r FFI ✓ SAN JOAQUIN LOCAL HEALTH 01511t111 <br /> CE USE: 1601 E. Hazelton A"ve,. , Stockton, CA 95205 Permit No.� /a3? <br /> Telephone: = (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From Date Issued <br /> f ! Complete In Triplicate <br /> Application is hereby made to the San Joa uin Local cal Health District for a permit, to 'construct 1 <br /> and/or 'install the work herein described. This application is made in compliance with San , <br /> Joaquin County Ordinance No. -,4862 and the Rules and -Regulations of the Sa.n .Joaquin-Local Health ' <br /> District. <br /> EXACT STREET ADDRESS o <br /> ' - CITY/TOWN <br /> Owner's Name . <br /> Address b Phone 3 - <br /> City. <br /> Contractor's Name <br /> License#,:3 6q Phone 3 (r,Cj-33S© <br /> _TS CERT'I ICATC OF 1,f0#tK�tAtJ`S C t PENSA7I0"'1'�'JSL1RANn Ol`ZIFTL`E'IIITFT <br /> TYPE OFWORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ '� � ? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ a(' <br /> PUMP INSTALLATION [a , .WELL <br /> REPAIR❑ PUMP REPLACEMENT <br /> i <br /> DISTANCE TO NEAREST: SEPTIC `TANK` S�W.ER LINES -7S`` PIT PRIVY'._ -mak <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL <br />.Industrial CONSTRUCTION SPECIFICRTIONS + <br /> Cable Tool Dia. of Well Excavation_ <br /> ___ _l _Domestic/private ; Drilled Dia. of Well Casing <br /> _ f <br />__,___Domestic/public Driven ,Gauge o Casing <br /> I rri gg ati-on <br /> Gr-a-vel--Pack: Depth-of=Grout:Sea �- �� <br /> Cathodic Protection Rotary Type af,Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed by: - 3 <br /> PUMP INSTALLATION: Contractor <br /> -rte <br /> ` <br /> Type of Pump <br /> PUMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION -OF WELL: Well Diameter <br /> pproximate Depths "" <br /> Describe Materia and Procedure A <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc " <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: k <br /> i certify that in the performance of the work for which this permit is issued, I shal'i <br /> not employ any person in such manner as. to become subject 'to Workman 's Compensation <br /> laws of California. " <br /> C WILL CALL 'FOR A GROUT INSPECTION PRIOR TO GROUTING_"AND •A.,FINAL INSPECTION. <br /> 3 t <br /> aIGNED TITLE: DATE: <br /> DR W PLOT L N ON. REVERSE SIDE <br /> 1HASE I <br /> FO DEP RTMENT SE ONLY <br /> IPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> -PHASE .II-GROUINSPECTION <br /> NSPECTION BY - PHA-SE IIT F-I-NAL-1NSPECfiI-ON <br /> �" 3 DATE � -/ S '�� INSPECTION BY DATE z7 7 <br /> H 1426 R -77 - - <br />