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SAN J�enn LOCAL, 'U15fKiCT <br /> FOR OF-fTCE USE: 1601 E. Hazel ton .,ton, CA 95205 Permi t No...Zf_/ .S'/ <br /> Telephone (209) 466-6781 <br /> Z APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued . -�$" <br /> This Permit Ex •jres 'l Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the -San Joaquin Local Health District for a. permit to construct <br /> and/or install the work herein described. . This application .is made in compliance with San { <br /> Joaquin- County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health f <br /> District. <br /> EXACT STREET 'ADDRESS 414 CITY/TOWNc1 .' �— <br /> Owner's Namephone -=' <br /> Address t -. S: City S <br /> Contractor's Name s v� Li cense# i Phone 32 q AY6 P -, <br /> IS CERTIFICATE OF WORKMAN'S 6,1PENSATION INSURANCE ON FILE WITH SJLHD? YES -N, NO <br /> TYPE OF WORK (Check) :, NEW WELL VJ DEEPEN [I RECONDITION DESTRUCTION d., r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 � L <br /> PUMP INSTALLATION ® PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /O Q SEWER LIMES 10 6 PIT PRIVY aC <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL LfL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /0 <br /> _Domestic/private Drilled Dia. of Well Casing `r <br /> Domestic/public Driven Gauge of Casing �/"� 16 0 __. _ <br /> Irrigation 3C Gravel Pack Depth of Grout Seal <br /> Cathodic Protection "--.Rotary Type of Grout C+_ <br /> Disposal Other Other Information <br /> Geophysical `� „ Surface Seal Instal ed. b <br /> PUMP INSTALLATION: Contractor c" -� <br /> - s <br /> Type of. Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: . Well Diameter Approximate` Depth <br /> Describe Material and Proce ure- _ . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance. <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the Sarf:'Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that 1 n 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 -Wbrkman's Compensation <br /> laws of California. " <br /> I WILL ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED { -.-� r TITLE: q,v �Z ;r= DATE{:_ f <br /> f <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHA E II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE/7 INSPECTION BY DATE <br /> Y <br />