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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICEUSE: /1601 E. Hazelton .Av '. , ,.S ckton, CA 95205 Permit No. d_/� <br /> a. Telephone: 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In 'Triplicate <br /> Application is hereby made to the San Joaquin Local Health District,for a ,permi.t to. construct <br /> and/or ;install the work herein described. This appl,ication. is made .in compliance with San <br /> ,'oanu�n County Ordinance No. 1862 and. the Rules and Regulationsof .the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 3z/S- !j � ,4� ' CITY/TOWN :S c,,6;4 , aJ <br /> Owner' s Name /-• tea/ v Phone- 9-3%- .5 J_ <br /> Address .. City <br /> Contractor' s Name ✓za UfvGLi cense ] Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATTO"! INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN K,10&At-SEWER LINES ,apa4-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ��Cable Tool Dia. of Well Excavation <br /> X'�Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 G-/X , <br /> Irrigation Gravel Pack Depth of Grout Seal 4T-0 I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal '"" Other Other Information <br /> Geophysical <br /> _._Surface Seal Instal3,e0_b ..: <br /> PUMP INSTALLATION: `` Contractor.__.-. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done - <br /> DESTRUCTION OF WELL: Wel] Diameter '` ' Approximate Depth <br /> Describe Material and Procedure - <br /> E <br /> F <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 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 CA FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: _ <br /> tc-�-x.c�� DATE- Q- 2-3 -7 F <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Z__�PPLICATION`ACCEPTED BY DATE 3 <br /> 7 6a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II ' FINAL INSPECTION <br /> INSPECTION BY DATE S .7e INSPECTTON BY DATE 6G-�, ?$ <br />.H 1426 RPv: 19_77 ti nv <br />