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SAN JOAQUIN LOCAL,HEALTH- DISTRICT <br /> sFFICE USE: "� �� S CA 95205 -Permit No. 33-� <br /> 1601 E. Hazelton Ave. , tockton, <br /> s Telephone: (209) 466-6781 <br /> .R Date Issued �a <br /> APPLICATION FOR WELL :CONSTRUCTION OR PUMP PERMIT <br /> to 1 etre I n Triplicate . <br /> APP lication 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 <br /> District. ivCJ7— 1'2 the San Joaquin Local Health <br /> i aF /yto.B.PISaw! 7.ri��r sCc7�icx/ <br /> CITY/TOWN Sl.�, <br /> EXACT STREET ADDRESS i 9 34S' - n,n <br /> �,h <br /> Owner's Name Phone <br /> E Address ,E-, 4N :� _-City ac �on1 <br /> Contractor's Name v rl4 o �.�/,.� �� y License# .3�v»,�- _Phone N7- y7a.s� <br /> IS CERTIFICATE OF WORKftAN'S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES O. <br /> �M y�-..:y_ ,-_.R.. y rY •._. ...,-. . .,.. r.� -. .fir .�..- �b��.=__�T ��- <br /> �4 IY.� .. ...... <br /> . .. � ,� <br /> TYPE OF�'WORK"(Check-)� #"-NEW'W£LL DEEPEN j~7 RECONDITION [' DESTRUCTIONS <br /> ;r WELL' CHLORINATION Q "r WELL ABANDONMENT 0 OTHER 0 - w <br /> t PUMP INSTALLATION Q 'PUMP REPAIR p"` RUMP REPLACEMENT ❑" <br /> ISTANCE TO NEAREST: -SEPTIC TAN SEWER SEWER LINES° 70 '- PIT PRIVY •e- C'� <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE OTHER--�- <br /> "PROPERTY LINE-2.�_PRIVATE DOMESTIC-WELL_.2� PUBLIC DOMESTIC WEA--�- <br /> .5 - ..:_ _.. __- .ter-..•._n-.«r- �....-..un+� <br /> k INTENDED US ' x. � TYPE OF`WELL3C CONSTRUCTION 'SPECIFICATIONS <br /> In ustrial Cable Tool Dia. of Well Excavation z ry <br /> Domestic/private ` _Drilled Dia. of Well Casing <br /> Domestic/public" Driven Gauge of Casing 6o pr, pec. <br /> YIrrigation _,Gravel Pack Depth of Grout Sea s`o ' <br /> Cathodic Protection 2Rotary _ '� Type of Grout All 7 <br /> Disposal. Other .I. Other Information <br /> _ <br /> ' .Geophysical Surface Seal Insta ed :� ie �, <br /> PUMP .INSTALLATION .: Contractor <br /> ;;Type of Pump ZAFK& H.P. <br /> PUMP REPLACEMENT: Q State Work Done ' <br /> PUMP REPAIR: ❑State Work .Dane - <br /> DESTRUCTION OF WELL: _ Well ,Diameter '11 -Approximate^Depth <br /> r Describe Materia ,,and, Proce ure <br /> Al <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 age'nt' s signature certifies the following: <br /> "I certify that in the performance of h " 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 TOII�GROUTING-AND- A FINAL INSPECTION. <br /> SIGNED :l;: -TITLE: s ` tDATE:` 1 Z <br /> DRAW .ON_REVER LIZ ( SIDE <br /> i F R EP, RTMENT USE ;9NLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �. <br /> PHASE II GROUT IN PECTION i. r PHASE II FINAL INSPECTION <br /> INSPECTION BY SegINSPECTION BY of< DATE 613111 <br /> EH; 14 26 Rev. 9/78 . �9 <br /> V 9 M <br />