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SAN JOAQUIN LOCAL HEALTH DISTRICT ~ <br /> FFICE USE: 1601 E. Hazelton tockton CA 95 Permit <br /> Ave. ,, 205 a it No. <br /> 6 <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Date Issued� ,�,g' <br /> This Permit Ex ires i 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 <br /> wistrict. a <br /> EXACT STREET ADDRESS S'/4j C,-rt ,w CITY/TOWN . <br /> Owner's NamePhone 41 7 7— 9 2f <br /> Address—, $�/ Ci ty <br /> Contractor' s Name License# <,)_ Phone'_ �� <br /> IS CERTIFICATE OF WORKMAN'S C01"PENSATIOIN INSURANCE ON FILE WITH S_JLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR® PUMP REPLACEMENT [� j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY #� <br /> SPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> - INTENDED USE TYPE OF WELL- - CONSTRUCTION .,SPECIFICATIONS �y <br /> Industrial Cable Tool Dia. of Well <br /> Domestic/private Drilled ' pia. of Well Casing <br /> Domestic/public Driven 4: Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other' Information <br /> Geophysical i Surface Seal Installed by: <br /> PUMP I-NSTAI:LArI-ON-:__ _-Contr-a-ctoI— — $� <br /> Type of Pump �._ H.P. p <br /> PUMP REPLACEMENT: []State Work Done a, <br /> PUMP REPAIR: '` <br /> ,(Mate Work�`D'one4&� 12t- <br /> DESTRUCTION OF"WELL: Well Diameter' , iT Approximate Depth <br /> Describe Materia an Procedure <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 CALLAORA GROUToINSPECIIO.NXRIOR TO GROUTING AND A FINAL INSPECTION. E <br /> SIGNED TITLE: DATE: <br /> IZ—DRAW PLOT 'PL N ON REVERSES E <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE dl031 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II-J FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ��—/S—�G <br />_H 142A Riau 19_77 <br />