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_ SAN JOAQUIN :, aCAL HEaAL7H DISTRICT <br /> �.. 2._ <br /> MR <br /> rfiCE:` SE: 1601 E. Hazel ton,,Aye� Stoei4ton, CA 95205 . Permit No. 6 <br /> Tel ephone;: ,, 49� 4fi6F,6781 1 <br /> �.._._ ;- : Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> + .a Exhi <br /> This' Perms gyres i 'Year:From ,fete .I�sued ,, <br /> Complete Ini—Tirlpl.iea e n.: <br /> ;y7 <br /> Application is hereby made to the San Joaquin=Local, Heal t ;,0�stric,�t _for ka perml t kto_.Construc't' <br /> and/or ri;nstal:l cthe:=:,work 6ere,i-n deS�cribed ;.>Th:nsgapp!.Acatlon.:5rs fade,;an':coff!plj,an,cg wi,th-,;San <br /> Joaquin OoiFnty)cOr:di-na-nc;e No. (il�62,apd the �Rules_anl,:.Reg latianip,,Qf, the San;AJoagg?p:,,Local,;.Dealth <br /> District. <br /> EXACT`•STRET-'f4IRE55S CTTY/TOWN ' } 9t1 r%� <br /> Owner's Name _ T" Phone 3� <br /> Add'rty <br /> �ss Q <br /> .. C , <br /> Contractor's NameIssed _ _ CL. a! Li cense# 337,0 Phone �7.�3 377 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'3 FINSURA1110E ON FILE' WITH SJLHD? YES��X NO- <br /> Tl YP£ OFu'WORK-(Check-) : . -NEW WELL CO` ..DEEPEN 0. RECONDITION Q - DESTRUCTION( <br /> ( WELL CHLORINATION E3 WELL ABANDONMENT 0 OTHERf -- r <br /> PUMP INSTALLATION 0 PUMP REPAIR CD PUMP REPLACEMENT ❑ J r <br /> s ' <br /> DISTANCE TO NEAREST: SEPTIC TANK iIJO SEWER LINES <br /> _ � PIT PRIVY - ----- t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEPAL£ PIT .�—. OTHER <br /> i PROPERTY LINE RIVATE DOMESTIC WELL --3"PUBLIC DOMESTIC WELL--- <br /> I'NTENDED USE TYPE OF WELL CONSTRUCTION SP:ECIFIC_ATIONS <br /> Industrialable Tool Dia. cif Well ExcavationesfSo` <br /> Domestic/private Drilled ' Dia. of Well Casing ,• <br /> Domestic/public Driven Gauge of Casing /d <br /> Irrigation Gravel Pack Depth of Grout Seal 6 cFY•. . <br /> Ca-tKodic Protection Rotary Type of Grout q -- <br /> Dlf�posal Other Other',Loformat�on ...-- `. <br /> Geophysical Surface Seal-Ihsta_led: - i.-- <br /> PUMP INSTALLATION: Contractor <br /> 's Type of Pump !H.P. - <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: QState.,Work�Do°ne <br /> DESTRUCT3,ON__OF .WELL:_:, _Well Diameter . ApRroximateNDepth <br /> . z Describe Material and Proce ure e f <br /> I hereby certify that I have prepared this application and that the work. will be done in accordancE <br /> with Sanfjoaquin County Ordinances, State Laws , and Rules and Regulations of-the San Joaq in Local <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 Cal i.fo_ rniar." -^ <br /> I WILL CALIN ECTION. <br /> s, O-R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL <br /> S I-GN ED-- , T3-_T: E, DATE <br /> j ON REVERSE SIDE <br /> DR W PLOT PLN <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ', <br /> APPLICATION, ACCEPTED BYE DATE <br /> ADDITIONAL :COMMENTS: <br /> PHASE II GROUT: INSPECTION ` PHASE III FLNALANSPECTION <br /> ' INSPECTION BY DATE / INSPECTION BY -DATE - l 7 <br /> f <br /> i - <br /> cu <br /> M <br /> 1_L 7.$. - <br />