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F lbo /1601 <br /> SAN JORQUIIV LOCAL. HEALTH DISTRICT <br /> FILE USE: E. Hazelton Ave.., Stockton, CA 95205 Permit No. — bQ <br /> Telephone: (209) 4666781 <br /> U APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ices :1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for apermit to construct <br /> . and/or install the work herein described. This. application , is made in compliance with San <br /> �?oao ��n County Ordinance �i 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District: <br /> EXACT STREET ADDRESS.. e Z CITY/TOWN U[7' <br /> Owner' s Name 'R _. Phone <br /> Address y4 City_ c-40, <br /> Contractor' s Name Li cense# !f 3 714'� P hone coy.. <br /> IS CERTIFICATE OF WORKMAN'S COMPS A 0"l INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (C.heck) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTED OTHER❑ <br /> PUMP ,INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE. TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> = PROPERTY 'LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information S <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> I <br /> , PUMP Rte' PState, Work Done <br /> « DESTRUCTION OF WELL: Well . Diameter pproximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have phepared this application- and-that the work.w lel, be.done -in accordant( <br /> with San. Joaquin CountyO;rd nancesi,.State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. -Home owner. oe 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. " i <br /> , I WILL CALL kORA GROUT INSPEC ON RI.OR—TO GROUTING AND A FINAL INSPECTION. 1J <br /> 'SIGNEDLE: DATE: L <br /> T PL N REVERSE SIDE) <br /> FOR PEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> (ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> ♦INSPECTION BY Q` OATS INSPECTION BY DATE <br /> IN 1499 0.211 19.77 1 /7R 'JM <br />