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SAN JOAQUIN-,.LOCAL .H.EALTH DISTRICT <br /> FQR OFFICE- USE: 614 `1601 E. Hazelton Ave. , FStoc-kton, CA 95205 Permit No-772T <br /> if Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex i.res- 1 Y'ear3 From Date. Issued <br /> J 4 <br /> Complete In 'Triplicate) I <br /> Application is hereby made to the San Joaquin .Local . Hea1th .-District fora permit to construct <br /> and/0'r; i'nstalI the�work -herein 'descri:bed.. —This application.,is;made 'in 'compl1ance with San ... <br /> Joaquin CauntylOrdin'ance .No. 18.62 and .the Rul; sand R u1 do s of the. San Joaquin.'Local ..Health <br /> District. <br /> EXACT STREET'ADDRESS ` b CITY/TOWN_ <br /> Owner's Name o , € Phone l — <br /> Address City i <br /> Contractor' s Name j�1 C� /�Z. �l�r�ao� �� �p cerise# Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURANCE ON_FILE -WITH SJLHD? YES2 NO-- <br /> TY PE <br /> OTYPE OF WORK (Check) : NEW WELLIA DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] .... � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERfJ <br /> PUMP INSTALLATION �Q PUMP REPAIR❑ PUMP REPLACEMENT ❑. <br /> DISTANCE TO NEAREST: SEPTIC TANK,4Z9 SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL FIELD11�_V/CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - 'PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS_.` <br /> Industrial ' Cable Tool Dia. of Well Excavation 42 <br /> I---Domestic/private,. Drilled Dia. of Well Casing <br /> Domestic/publ J c '" _-,= Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Gout Seams <br /> Cathodic Protection _4=Rota ry - {Type of Gr ut 5 <br /> Disposal ` _,Other Other Information ,- r <br /> Geophysical Surface --Seal I nstaTled by:, L <br /> PUMP' INSTALLATION: Contractor 49 _��.-r> <br /> Type of Pump_�_ H P .� <br /> PUMP REPLACEMENT: State Work Done ' <br /> PUMP REPAIR: ❑State Woi k Done , fF <br /> DESTRUCTION__F_WELL: - Well Diameter -__ - - - - _ Approximate Depth .z <br /> Describe Materia -and. Procedure , <br /> I hereby certify that I%have prepared this application and that the -work will be done in accordant( <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 ire such manner as to become subject to Workman's Compensation . <br /> laws of California." <br /> I WILL CALL 0 GROUT INSPECTION PR 0 , TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: fled �f" DATE: '—��� <br /> D W-PL T.", L`-.N ON REVERSE, SME) <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE "r- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III fINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/' DATE <br /> EH 1426 Rev. 12-77 '- � � 1J78 - 2M <br />