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! <br /> SAN JOAQUIN';LOCAE`� HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazel,ton -Ave :; S.toc:kton, ,_CA 95205 Permit No.7 <br /> - Telephone: i,'209) 466-6.781,.• . <br /> Date Issued3- 3-J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -- <br /> ., . . i. � .0 .' ;, _ i t - <br /> Thi s,Yermit;,Ex ire.srJ Ye:ar.. ;From,,Date Issued.., ,' $ <br /> •Complete :In .Tri pl i date. ' <br /> Application is hereby made to the San Joaquin Lotal'2He'al-th' District fora permit to construct '. <br /> and/0, i n'sta`l l the=wo"k hL-e0 n descri bed. Thi's appl i catiVn , i s made An compliance wi th...San�'.,,` <br /> tioan ��nCounty I"Ord;i mance` lyo 18'62 and the Rules,and -Re�gul a�t•i ons --of- the, San Joaqu ,n Lo 'al- -Health <br /> EXACT Sl REST ADpR'. 5 )`-�'"' CITY/TOWN� M� <br /> Owner's Name Phone l�( <br /> Address City <br /> Contractor' s Name �� a..,' iLicense&?O23. Phone . 4 <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATION! INSURANCE ON FILE: WITH SJLHD? YES 740 <br /> TYPE OF WORK (Check) : NEW WELD DEEPEN [i RECONDITION Ce'--'--DESTRUCTION[] <br /> WELL CHLORINATION L7 WELL ABANDONMENT.0 OTHER 0 ' <br /> PUMP INSTALLATION 0 PUMP REPAIR C?-� PUMP REPLACEMENT ❑ . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CE.SS,POOL'/SEEPAGE PIT. . OTHER <br /> ' RROPERTY LINE -. PRIVATE DOMESTIC'WELL'=^T 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 /> Disposal Other , Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done tJ ' <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL.: Well Diameter pp roximate -Depth� p <br /> Describe Material andProcedure <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 CALL FDR A GROUT ,INSPECTION PRIOR .TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �.9• �p <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> PHASE i <br /> FOR DEP RTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED BY DATE 3 17 <br /> ADDITIONAL COMMENTS: I z z <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> EH 1426 ' Rev. '12-77 ,:. _ 1"178 2M <br />