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SAN JOAQUIWILOG&OHEALTH DISTRICT <br /> F±EFFICE USE: 1601 E. Hazel tanv <br /> .,�Avev <br /> Tel6p , Slt-Xtton, CA 95205 Permit No._1L5qZ_ <br /> �209) 466IF,6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> P, er mirft <br /> —1 Tt_�..j <br /> QEX P ires <br /> 71..,7 CLss <br /> t <br /> R; -ued, <br /> ri p j e-,&,p Irk J�r f p 8Lt qT <br /> 0C <br /> by,made to the San JoaqrjfH <br /> iAppii-cation is here <br /> a n d H 6,t 1',t f i tri f t <br /> oaou in =worn eYe P6,hoi tb--,cors t rua <br /> "Th <br /> W1 t h­S a n, <br /> Elistri at.�fa'n-s;�ofthe,cS-,an'tjoa:quiti�Lo6ale-Health <br /> EXACT] <br /> S F G.i-T, <br /> ' <br /> TOWN <br /> s Name 42 <br /> Owner <br /> Address Phone <br /> Co.ntrac,tor s Nam <br /> License�3k#��., Phone <br /> IS CE*PTTF'TffATF nr7 <br /> COMPENSATION INSURANCE ON FILE 4JTTP SJLND? YES <br /> NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN' [] RECONDITIONS NDESTRUCTION 0 <br /> WELL CHLORINATION WELL ABANDONMrq-T70 OTHER 0 <br /> PUMP INSTALLATION Ej PUMP REPAIR(] PUMP REPLACEMENT <br /> DISTANCE, TO NEAREST.: SEPTIC TANK SEWER' LINES <br /> SEWAGE PIT PRIVY, <br /> DISPOSAL -FIT— 'OTHER <br /> CrSSPOOL/SEEPAGE <br /> PROPERTY LINE , -, PRIVATE—DOMESTIC WELL PUBLIC. DOMESTIC <br /> WELL <br /> INTENDED USE 'TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br />_L__L __�a�ble Tool Di a. Of Well Excavation <br /> _Pome�tit/priv4te Drilled' <br /> i <br /> o <br />—Domestic/public Dia. f Well Casing <br /> --------., ven - — Gauge of Casing <br /> Irrigation : Dri <br /> Gravel Pack Depth <br /> of :Grout Seal <br />---___Pathodic Protection Rotarype of Grout <br /> Disposal Other TY <br /> Geophysical Other .1nform'ation —------ <br /> Surface Seal Installed by: <br /> LIM-1 11ST111ATION:. Contractor, <br /> Installed b <br /> Type' of pump H <br /> UMP .REPLACEMENT: .5075tate Work Don <br /> UMP REPAIR: <br /> E]State Work Done7 <br /> ESTRUCTION OF WELL: Well Diameter . <br /> Describe Materldl and Procedure Approximate Depth <br /> hereby certify that I havie prepared this application and that the work will be done in ac cordance, <br /> th San Joaquin County Ordinances , State Laws , and kulos and Regplations Of the San Joaquin L6cal <br />,alth District. :Home Ownef, or licensed agent-'s signatdre 'certifles the following: <br /> III certify that in. thb perfo: rmance. off' thb, wbrk for which' this ' <br /> not employ any I person i' permitAs .issued, I shall <br /> laws of-Cal ifdrn'ta. '" n such mariner' as; to� betome" subject to WorkmaWs Compensation . <br /> WILL CALL FOR A GRO <br /> UTJNSPECTIM PRIOR.TO',MUTLWANd VFINAL .INSPECTION. <br /> LONED <br /> TITLE C� <br /> DR W PLOT ;PLN ;_. <br /> ON REVERSE SDATE?" <br /> FOR DEPART;SE I SE :ONLY <br /> PLICATION ACCEPTED BY <br /> DITIONAL COMMENtS _ DATE. <br /> PHASE: lj ' GROUT :INSPECTION <br />>1PECTION 6Y <br /> INSPECTION <br /> ;DATE <br /> INSPECTION <br /> ------------------- BY. <br />