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V" SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Ftock4on, CA 95205 Permit No.�1!Z14 ,-7- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/2/,2 Wig'. <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 permit to construct <br /> and/or install the work herein described. This application is .made in compliance with San <br /> ,oaQuln County Ordinance No."' 1862 and the Rules and- .Regulations. of the, San Joaquin Local Health + <br /> District.' <br /> EXACT <br /> .STREET ADDRESS CITY/TOWN <br /> Owner's Name - Lp, Phone <br /> Address <br /> City <br /> -- <br /> Contractor's Name &A. j2,5 & <br /> tp,-` &42h ^a r J License# ;?ZoV3 Phone_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN TNSURA1110E ON FILE WITH SJLHU?._ . YES X AVO_.. - <br /> TYPE OF WORK (Check) : NEW WELL[, DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Ci OTHER ❑ Q <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> o <br /> DISTANCE TO NEAREST: SEPTIC TANK loo'* SEWER LINES PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD 1 o/ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL T <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation_ zz � <br />---X—Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public t: Driven h ,�.� Gauge of Casing <br /> Irrigation tLGravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other - Other Information % ,z� <br /> Geophysical _ .. ,Surface Seal Installed by: Icy ,/�,� ) j <br /> PUMP INSTALLATION: '''Contractor <br /> Type--of Pump <br /> PUMP REPLACEMENT: ❑State Work Done - <br /> PUMP REPAIR: Q State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe Material and Procedure <br /> i <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 offthe 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 LNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: DATE: /gyy <br /> (QVAW PLOT PLAN j2NIREVER SIDE <br /> PHASE I FOR DEPARTMENT USE Y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR9yT INSPECTION PHASE III FIN L INSPECTION <br /> INSPECTION BY DATE /,;2 —jr' INSPECTION B �,,a DATE <br /> Cu 7Bne n_. wn -i-. - CA nor <br />