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S!''__1OAQUIN LOCAL HEALTH DISTRICT <br /> EICE USE: 1601 E: ,,azelton Ave. , Stockidn, C'A 952L�a' Permit No. _-7 <br /> w Telephone: (209) 466-6781 <br /> 41 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued —�� <br /> (,Complete In Triplicate)' <br /> Application is hereby made to the San Joaquin Local Health'-'District for a permit to construct w <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'.Regul•ations of the San Joaquin Local Health <br /> District. <br /> EXACT- STREET A DRESS k <br /> _ CITY/TOWNJTty� <br /> Owner's Name vv _ Phone <br /> Address <br /> 'v City <br /> Contractor's Name U T `V>tm License# �2 Phone <br /> IS CERTIFICATE ,OF,WORKMAN'S, CO""PENSATION INSURA"dCE ON FILE WITH SJLHD? YES 0" ' <br /> TYPE Or WORK (Check) : NEW WELL 0 DEEPEN RECONDITION ® DESTRUCTION[� <br /> WELL CHLORINATION D WELL ABANDONMENTI1 OTHER <br /> PUMP INSTALLATION PUMP REPAIR©_. . .PUMP REPLACEMENT [a CY. <br /> DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LIjVES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD v�-t- CESSPOOL/SEEPAGE PIT— OTHER Y f� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL__.___-_.. PUBLIC DOMESTIC WEA <br /> NTENDEQ"USE��` "" ` '' TTYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industria -' - -' Cable ToolDaa.._of lel-1Excavation - <br /> ...Domesti c/pri-vate Dri�l l ed ' Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Sea , <br /> Cathodic Protection Rotary Type of Grout <br /> 4 Disposal . Other ` Other Information <br /> 'Geophysical Surface Seal InsLaTled b <br /> PUMP-INSTALLATION: - Contractor ` <br /> Type of Pump H• <br /> `U P REPLACEMENT: _ Q State Work Dane <br /> .,PUMP_REPAIR: �w,... ., _ <br /> Q'State Work Done _ ¢ <br /> DESTRUC7ION;6F WELL: Well Diameter Approximate Depth <br /> x <br /> Describe' Materia an Proce ure <br /> fI 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 employ any person in such manner as to become subject to. Workman's Compensation <br /> laws of California. " y <br />: I WILL CALL FORA-GROUT ,I P CTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ln`� <br /> D PL T PLAN ON REVERS IDEJ. <br /> ' FOR DEP RTMEN USE .ONLY <br /> PHASE I <br /> PPLI ATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.: <br /> PHASE JI OUT INSUCTTONPHASE I I ' INAL INSPECTION <br /> INSPECTION BY 6 , D IiS �1CTI <br />'£H 14 26 Rev. 9/7 ." - a�. "' f 78 { 2M <br />^ y - <br />