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SAN JOAQW N.LOCAL HEALTH DISTRICT { <br /> Permit No. - <br /> FOEFFRE USE: 1601 E. Hazel.,ton Ave: , Stockton, CA 95205 Perm �! <br /> -- Telephone: (209): 466-6781 Date Issued /�3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT (af <br /> This Permit Ex i.res 1 Year From Date Issued <br /> jljComplete In Triplicate <br /> , <br /> alth <br /> Application is hereby made to the San Joaquin Locall�cationDi}stmade inrcompliancetwith.nSan <br /> uct <br /> and/or install the work herein described. This app <br />. Rules and Regulations of the San Joaquin- Local Health <br /> Joaquin County Ordinance No. 1862 and the <br /> District. pp� <br /> SC rPt CITY/TOWN Int o� <br /> EXACT STREET. ADDRESS ' ? �. <br /> F Phone sZIq <br /> Owner's Name <br /> City. a� . <br /> Address _ ,. - <br /> �� � License#.3y�'7s�' Phone_ ��-�-��.� - <br /> Contractor' s Name ; <br /> .ILCERTTFICATE OF WORKMAN'S COMPENSATION INSURAII SON FILE WITH SJLHD?� YES` .' i10 � <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION[D <br /> WELL CHLORINATION E3 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ :,, PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO .NEAREST: SEPTIC TAN C' SEWER LINES"" PIT PRIVY <br /> SEWAGE DISPOSAL FIEtrD•.t CESSPOOL/SEEPAGE PIS— BOTHER ` <br /> PROPERTY LINE -• PRIVATE- DOMESTIC WELL ----� PUBLIC DOMESTIC WELL <br /> TYPE OF WELL �Y CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE C. <br /> Industrial Cable Tool Dia. of Well Excavation W� <br /> Domestic/private g —Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal . <br /> �_Irrigation Gravel Pack�� , <br /> Cathodic P.rotecti on <br /> Rotary -� a' Type of Grout <br /> Other � Other Information <br /> Disposal . <br /> Surface Seal Installed b :" <br /> Geophysical Y <br /> PUMP INSTALLATION: Contractor H.px <br /> - Type;0f Pump �, <br /> PUMP REPLACEMENT: State Work Done <br /> MP REPAIR . - w�.�_ ❑State-,AWorka i)one _ - _ <br /> _ --- x Approximate.Depth <br /> DESTRUCTION OF WELL: Weil-Diameter <br /> Describe Materia an Procedure * - <br /> 4 be don <br /> k rdak <br /> I hereby certify that I have prepared this aplican�iulesand <br /> andRegulat�onswoflthe San eJoaquin in oLocal <br /> W ith San Joaquin County Ordinances , State Laws , <br /> 'Health -Dist rict. 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 i•n such manner as to become subject to workman's Compensation <br /> laws of California." <br /> �. I WILL .CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: �a <br /> f SIGNED DR W PL T L N -ON REVERSE DE <br /> f f. FOR )EP RTM ENT USE ONLY <br /> PHASE I DATE - <br /> APPLICATION ACCEPTED BY- <br /> ADDITIONAL COMMENTS: PHASE IIT INAL INSPECTION . <br /> E PHASE 11 GROUT.I NSPECT.I ON DATE <br /> -DATE-- INSPECTION BY_ <br />