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f <br /> - g SAN --lOAQUIN •LOCAL HEALTH DISTRICT ? <br /> �I-C E: r 1601 E. Hazelton Ave. , Stockto` "CA 95205 Permi t No. �79 j.13_ <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued 1, <br /> Complete In. Triplicate j <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 /> ,:oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin_. Local Health <br /> DiStr'Ct. <br /> EKACT STREET ADDRESS f CITY/TOWN <br /> �A <br /> Owner' s Name Phone <br /> Address_ City.. <br /> Contractor' s Name . t License#O-W12 Phone 1d3 <br /> IS CERTIFICATE OF WORKMAN'S COl�1P' ATIOIN TINSURA"!CE ON FILE WITH SJLHD? YES- NO <br /> TYPE OF WORK (ChecIV �WELL-L --- DEEPEN ❑ RECONDITION C] DESTRUCTION❑ <br /> WELL CHLORINATION p� 'WELL'-ABANDONMENT ❑ OTHER 0 1.1 <br /> _—PUMP:INSTALLATION ❑ PUMP REPAIR❑ PUMP-REPLACEMENT ❑ �p <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY <br /> NEAREST-:- - <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> it 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 /> �Zomestic/private Drilled Dia. of-We"11 �Cdting, <br /> Domestic/public 4 Driven Gauge :of Casing ! ' <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic <br /> Pro tection--- ary Type of+Grout <br /> Disposal Other Other Information Ar <br /> Geophysical Surface Seal Instal e by: <br /> PUMP INSTALLATION: Contractor r ,. . <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: ]State Work Done ` J' <br /> PUMP REPAIR: ❑State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter , n Approximate Depth <br /> Describe Material and Procedure <br /> I , <br /> t <br /> LI 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 ny pe so in such mannefas to become subject to Workman's Compensation <br /> ws of Ca T forni . <br /> i L CALL FO ,GR TP CT . ._- .RIO TO GROUTING AND A INAL INSPECTION. -_ <br />,SIGNED TITLE: DATl <br /> (DRAW PLOTP,L N ON ''REVERSE SIDE <br /> FO&-DEPARTMENT' USE ONLY <br /> PHASE,.I _ L <br /> APPLICATION ACCEPTED BY DATE ^z <br /> ADDITIONAL COMMENTS. ' <br /> PHASE- II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,OI-Zo u1 DATE S <br /> Y � l YT8 2M <br /> iF��''14?h__ RAv '79_77 — �.."'�'-m .. " . - � �.a„�_ -- - � - - ----- . . � ,. <br />