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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PR OFFICE USE: 1601 E. Hazelton Ave, , to-,,kton, CA 95205 Permit No. 79- 3� <br /> Telephone; (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> ..(Complete In Triplicai;e) <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 />; Joaquin County Ordinance No. 1.862 and the Rules and Regulations ,of the San Joaquin Local Health <br /> -District: <br /> EXACT`"STREET ADDRESS_ " t �t� _ f,I CITY/TOWN <br /> Owner's Name Phone g,�9• _ �7 <br /> Address <br /> C4 11A Ci ty",rdegg- 2,5..3,31, " , <br /> iContractor's Name License Phone �k - 29/n_ <br /> I5 CERTIFICATE -OF WORKMAN'S COMPENSATION INSURA"ICF ON FILE WITH 'SJLHD? YES 0 <br />'..TXPE_�.OF WORK-(Check)-:—NEWk-WELDW DEEPEN 0-7 RECON DI-T-1°ON-0 ` -DE"ST RU CTI'ONM-L./ <br /> LO <br /> WELL CHI NATION p WELL ABANDONMENT Q OTHER( Q <br /> PUMP INSTALLATION CI PUMP REPAIR❑ PUMP REPLACEMENT Q W <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINESL,S +, PIT PRIVY <br />` SEWAGE DISPOSA4 FIELD�1 CESSP OL/SEEP�GE PIT --- OTHER - " <br /> PROPERTY LINF/&+PRIVATE DOMESTIC WELL.��� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />{Industrial ifCable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of' Well Casing ' <br /> Domestic/public Driven Gauge of Casing Adx, Ido <br /> Irrigation '4 Y Gravel Pack Depth of Grout Sea r <br /> Cathodic Protection Rotary' " Type of Grout <br /> Disposal <br /> Other Other Information --— <br /> r <br /> . Geophysical i -Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 01-ozlA <br /> Type of Pump -- H.P. <br />. PUMP REPLACEMENT: ° p State Work Done <br />! PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF�WELL.:. . _We.11 .Diameter : .. ..App•roximate Depth �- - -- <br /> Describe Materia and Procedure <br /> h <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 As issued, -I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. G , <br /> I. WILL CAL 0R A CiROUV I CTION PRIOR TO GROUTING' AND A'FINAL INSPECTION. <br /> SIGNED_:. - f <br /> r TI•T.LE: �nc DATE: <br /> -(DRAR PEOT PLAN ON- REVS SI E <br /> FOR, DEPARTMENT, USE ONLY <br /> PHASE 1 vin <br />'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS . 7 <br /> PHASE II GROUT INSPECTION + .?f., �sPHASE III FINAL INSPECTION <br /> INSPECTION BY N. DATE INS PECT;IUIV" BY DATE �7 <br /> EH 14" 26 Rev. 9/78 1'�0 , _ � Ll X 9 9/7 W 2M <br />