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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FPICE USE: 1601 E. Hazelton Ave. , Spockton, CA 95205 <br /> -----�=' � <br /> Telephone: (209).,.4166-6781 <br /> Permit No. <br /> p (2,09).,.416-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Eomp Tete I n' Trip 1 i ca to}, <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 <br /> District. <br /> EXACT' STREET ADDRESS <br /> Owner's Nam . ,, . CITY/TOWN <br /> e 1�[I^ //� lzS��LL � �3 /c`�v'�' - <br /> Address _ Phoned .27 <br /> ty <br /> Contractor's Name -- <br /> i-� &License# FJ� Phone /6 7F- <br /> ` IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES !� <br /> � TYPE OF WORK (Check) : NEW WELLl� DEEPEN❑ RECONDITION � <br /> ONDITION ® DESTRUCTION f-1 <br /> f WELL CHLORINATION ❑ TELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK/-'re-/ SEWER LINES/, ..�� PIT ,PRIVY -!/arY• <br /> SEWAGE DISPOSAL FIELD/ CES 0/S F:PAGE OTHER <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELLA <br /> PUBLiC DOMESTIC WEL c� • p �' <br /> I INTENDED USE TYPE OF WELL <br /> —. -Industrial Cabl Toe Toe al CONSTRUCTION SPECIFICATIONS. <br /> Domestic/private Dia. of Wel Excavation � 77 v <br /> - — � _ - D.r, :l l.ed .n7a. af_._ te7_1 Gasang 1� _ <br />;_Domestic/publ i c ari.v-en_. <br /> 7Irrigation-- - --ravel Pack Gauge-Fof-Ca-si-ngg�- <br /> Depth of Grout <br /> -- Sea <br /> Cathodic Protection Rotar <br />� �_Disposal y Type ype of Grout <br /> _Geophysical Other Information <br /> 3 Surface Seal Insta <br /> PUMP" INSTALLATION: Contractors -- <br /> -. rn <br /> Type of Pum <br /> PUMP REPLACEMENT: H. <br /> ' ❑State Work Done % <br />'PUMP REPAIR: m. <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: f Well Diameter <br /> ., Approximate Depth <br /> Describe-Materia . an Proce ure w ` <br /> I hereby certify that I have <br /> with San Joaquin County .Ordnances,eStatesLaws,`�cationand lesdandthat <br /> Reg he work <br /> will e-Sane, i accordance <br /> Health-District. Home owner or'plicensed agent''s`ysignature certifies'�the following: Joaquin Local <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 ?Com ensation <br /> laws of California. _ p <br /> I WILL CALL- FOR A GRO INSPE TION! PRIOR TO GROUTING NDA'FINAL INSPECTION: <br /> SIGNED_ _ _ ' ,..�-..,.- # <br /> ` ` . D;4TEV y .. 7y <br /> PL �. <br /> ON..-REVERSE_ S.IAE <br />)HASE I OR EPARTM SE NLY - <br /> PP� LICATION ACCEPTED 8Y <br /> MITIONAL COMMENTS: DATE y a <br /> PfiAS;EII GROUT INSPECTIO <br /> NSPECTION DATE S �� P_NAS-F_j.I.I_F-I NAL-_INSPECTI_ON . <br /> H 14 26 Rev. 9/7 �' --`� INSPECTION. BY DAT - -do , <br />