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j "IN JUAIlUIN LUUAL HtALIN U1J I It ILI <br /> c MICE USE: 1601 Hazelton Ave. , Stockton, CA X05 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Aoplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> dnd/or install the work herein described. This application is made in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �j'j�' 7 L' rn ,'cE2 A vj�F CITY/TOWN E_5C_A4L)1✓ <br /> Owner's Name �17� �' j3 AVAILy Phone 067- <br /> Address <br /> 6 -Address 3t�,� 7vZ �• �)P/3vc'vt AIJtA City 6s(_P k 1 <br /> Contractor' s Name %p rbc .J Licensee,'/0 Phone <br /> '.S CERTIFICATE OF WORKMAN'S CO'1PENSATION INSURANCE ON FILE WITH SJLHD? YES JC NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION ® PUMP REPAIR❑ PUMP REPLACEMENT [I a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Ch <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor T d- ,4� <br /> Type of Pump ,S' H.P. .4jQ <br /> PUMP REPLACEMENT: 0 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 accordan <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, I shall <br /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUL IN ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 'zzs7�z <br /> DRAW PLOT PL N ON REVERSESIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE IIIfFINA6 INSPECTION <br /> INSPECTION BY DATE INSPECTION BYP/j , DATEF �/ <br />