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0. SAN JOAQUI'N .-LOCAL HEALTH DISTRICT <br /> OFFICE US�1,/ 1601 E. Hazel tan°.Ave. , 'Stackton, CA 95205 Permit No. '�� . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR ,WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex ices .1 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 incompliance with- San <br />', ,caquin County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health <br /> G,istrict. <br /> EXACT STREET ADDRESS �, `� cP CITY/TOWN <br /> Owner' s Name Phoneme <br /> Address cct <br /> City c t .tom <br /> Contractor' s Name License#,?SD d� Phone Y —6 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11,1 144SUR 10E ON FILE WITH SJLHO? YES NO <br /> ' TYPE OF WORK (Check) : NEW WELL 94-- :DEEPEN a' RECONDITION [] � DESTRUCTION[] <br /> f WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 r' <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> J.DISTANCE TO NEAREST: SEPTIC TANK IrO` SEWER LINES /6Vi PIT PRIVY <br /> SEWAGE DISP SAL FIELDS CESSP�L/SEEPAGE PIT OTHER <br /> . PROPERTY LINg5 PRIVATE DOMESTIC WELL A2 PUB.L C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation rQ' <br /> omestic/private DrilledF Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal # !fit OF <br /> r Cathodic Protection A,--Rotary Type of Grout z2f ,,,m•v �7T,&, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: �.� <br /> F <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump .* W.P. <br /> .PUMP REPLACEMENT: ❑State Work„Done � ' # <br /> PUMP REPAIR: QState Wor$” .Done i <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth f <br /> Descri be. Materi a.,. ,andcProce 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 Ru les and Regulations of the San Joaquin 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 California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR' TO GROUTING -AND A FINAL INSPECTION. <br /> #SIGNED TITLE: DATE: <br /> DR W., PLT PL N ON REVERSF-UnEl <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I �.. <br /> FAPPLICATION ACCEPTED BY DATE <br /> [ADDITIONAL COMMENTS: <br /> PHASE- I2 G UT INSPECTION -: PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE 3 1 77`� INSPECTION BY DATE 21 27 S <br /> `CLI 7/t nG, rl_ 14 77 - <br /> 1 /78 - <br />