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�- 61AIL �L�fj f it <br /> I?N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -To Age- mit No. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, GA 95205a011 <br /> r , Telephone: (209) 466-6781 Date Issued 3 y Z 6/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> M This Permit Ex ices I Year 'From Date Issued ; <br /> f My 4�? % C mplete In Triplicate <br /> Application is hee'6y 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 /> ,'oaQui n County• Ordinance No. 3862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS S`� gisr �`T A7 -.� —�°r`j s CITY/TOWN <br /> Owner' s Name 1,4 V Phone—km---a23 —� <br /> Address SS' City . U <br /> Contractor' s Name License# Phone U <br /> IS CERTIFICATE OF WORKMiAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT PI OTHER (,=, G <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation„ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> fDisposal Other Other Information <br /> Geophysical Surface Seal Installed 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: Well Diameter Z,A / V r Approximate Depth 00 f' <br /> Describe Material and Procedure / vH 5- <br /> f _ I G <br /> I hereby certify that I have prepared this application and that the work will be don 1 � co&a <br /> !with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 /> TITLE: DAT <br /> SIGNED !L DRAW PLOT PLIVN ON REVER E SIDE <br /> FOR DEPART USE ONLY L <br /> PHASE I DATEZ <br /> APPLICATION ACCEPTED BY �,/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 ?� <br /> ru 1110C fle.. 1 0_77' � - -- <br /> 1 7.8_. .2M <br />