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v� SAN JOAQUIN ,.LUCAL,; LALiH UlblKlUl <br /> Stockton, CA 95205 PermitFOR FFICE USE: 1601 E. Hazelton Ave. , <br /> No. ,�y_, <br /> Telephone: ; (209) 466=6.781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit .Ex fires 1 ,Year From Date'Issued °., <br /> 4, <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local -lth District -for a mi t. to construct <br /> pp <br /> r all the work herein described:. This application is made .in compliance with San <br /> and/onst4ealth <br /> uoaaui n County Ordinance 1Jo. 1862 and the Rules and Regulations .of the .San Joaquin o <br /> Cistrct. <br /> CITY/TOW <br /> EXACT STREET ADDR ✓ C�� " <br /> Phone . . <br /> Owner' s Name <br /> city <br /> Address � 3 Phone <br />. License <br /> Contractor's Name <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATIO"J INSURA"!CE ON FILE WITH 5JLND? YES ,0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [D DESTRUCTION <br /> WELL � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ . PUMP,REPLACEMENT C� <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION: SPECIFICATIONS U <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> r Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> RPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q StateWork Done <br /> PUMP- REPAIR: tate Work Done <br /> DESTRUCTION-OF WELL:: :Well- Diameter.-I Approximate Depth <br /> Describe Material an Proce ure ' <br /> tI hereby certify +that I. have prepared this application and that the work will be done in accordar <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 /> 3 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. f; <br /> TITLE: DATE: . 3 1 <br /> ,SIGNED D AW PLOT PL N ON REVERSE SI ' <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I DATE �79� <br /> ,APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA W11 INSPECTIONINSPECTION BY DATE INSPECTIONBDATE <br /> N . . ...� 1 78`: j�2I <br /> TW 1 d9F, Rnu '7'9-_77. . <br />