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_ SAN JUHt�U1N LUi;HL NLHLIH U1��A1195205 Permit No.� <br /> FOR FFIC <br /> E USE':.. E. Hazelton Ave. , Stockton, <br /> Telephone: ' 209) X66-6781 Date Issued - 4 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From. Date Issued <br /> ti Complete In Triplicate <br /> Aoplicat ion is hereby made to the San Joaquin -Local Health District iorca compliancewith nsanuct <br /> anal/or install the work herein described. This; applicat�on .is <br /> tinaquin County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distri-ct. <br /> CITY/TOWN <br /> EXACT STREET ADDRESS �^ <br /> Owner' S Name Phone �-� a <br /> . City . <br /> Address <br /> Contractor' s Name ' <br /> License#hoc Phone <br /> ?S CERTIFICATE OF WORKMAN'S COMPENSATIOM INSURANCE ON FILE WITH SJLHD? YES 7'�— t10 <br /> TYPE OF WORK (Check) : NEW WELLZ DEEPEN ❑ RECONDITION ❑ DESTRUCT-ION❑ <br /> WELL CHLORINATION [l WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE 70 NEAREST: R SEPT-IC,TANK -SEWER LINES - PIT- PR-IVY- <br /> -= <br /> SEWAGE DISPOSAL FIELD CES P40L/SEEPAGE PIT OT CRWELL <br /> .PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMEST <br /> INT-ENDE-D!,USE TYPE OF WELL CONSTRUCTION SPECI _ICATIONS <br />� Industr7al ,� :�,� A <br /> Cable Tool Dia. of Well Excavation " <br /> Domesti•ciprivate Drilled Dia. of Well Casing �" ) <br /> �Domesti c/public Driven Gauge of Casing <br /> ,�-- <br /> irrigation - Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection RotaryType -of Grout �.� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal' hnstal,led b <br /> PUMP INSTALLATION: Contractor H.P. <br /> i Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 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, T shall <br /> ' not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> k1 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED M TITLE: DATE: <br /> L4", <br /> R P PL N ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ! PHASE I DATE__L o �7B <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GR INSPECTION 4 _ <br /> INSPECTION 8Y DATE "(� � INSP£CTI4(V BY ATE f <br /> 17 8/_ 2M <br /> rii i nuc rl— 1')_77 <br />