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SAN JOAQUINmLOcA4:. ILTH DISTRICT <br /> CA 95205 EPermit . .3. EFICE US I601 E. Haze�tt�n;,�ve��,� � ,oc��ton,Telephon� �,�Og �i6- 781 �., , ed -a -7 <br /> APPLICATION FOR""iELL CONSTRUCTION OR :PUMP PENT <br /> f E', . .0 s 7 <br /> This . e , T ,. ear°. ri} t <br /> r�D711} e,kP._ Ing z.rlplX�cate.;:F =r.;.f ' `:r 13 1. f `if {1'.I'sF;. - ;•,i' .. <br /> Rppl i clati on is hereby made to the Sari Joaqu�rs � ocal� ,Heal#.� I��.r�tri:ct fog' • : <br /> permit tr�t�F cons�r�ct , <br /> andlow� install sta + r rarlc ;le.i-ei + de ar:abed� ;:-;T}his„apo"i,calt�oa�,.a� rade in..co pl <br /> dr:::.. 9 440 . .pkkoea,l.',.Health <br /> oao :;n :+�+Da r: i an S;,�,c�:=:n�1 Ei and t a:.R_ul es ,. Re pl of., t p' Sar boa a <br />✓b"i Str�`ct o�o�,. �L {v- 1:C}.i <br /> EXACTy �^ IF ^��y�-s }v g� y ( ' a..,! ? .)' , C I•T 1 y-,)A ` , <br /> ExACT I�Sf ,e4L A 't1I141� J 7 , 'u: a,:V; ' �l`, 5 7a�r:�ti�' lS 3. <br /> Pha <br /> Owner'`s Name ne <br /> Add. ... .n. s...V 'T'A' • r'_v n- =-r.:+......�-.aa.........v.e-.,..e-.--r:.. >..v..�-.-:.....w.a.e. <br /> Contractor's Name �I Licensei: Phone: = <br /> I� <br /> IS CERTIFICATE. OF WORICIAN S 'COMPENSATIO'N" INSURANCE Otl FILE. Wi'" 'SJLDD? YES' : .IaO� <br /> TYPE IQF-WORK (Che& NEW-WELIL DEEPEN-0 RECONDITION 0 DEST3IUCTI0�1© �- rt <br /> WELL CHLORINATION C3 WELL ABAN60M ENT--I - OTHER S <br /> PUMP.. I9t-STALLATION PUMP REPAIR PUMP REPLACEMENT,�...;� <br /> DiSTACE TO NEAREST: ? SEPTIC' TANK SEWER LINES ! PIS PRIVY! <br /> SEWAGE.DISP A FIEF r C SP00 /SEEPAGI= SIT-=— OTHER <br /> �e 1 <br /> PROPERTY LIN04PRINA E DOMESTIC, wtC PUBLIC. DOMESTIC WELL <br /> INTENDED USE l TYPE OF WELL "° CONSUUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Weil Excavation <br /> Industrial I --�-- a� <br /> y Domestic/private ' Drilled , Dia. f Well Casing <br /> ^Domestic/publ i s !I Driven Gavge of`I<asing <br /> 11i IrrigationsGravel Pack - ' Depth of Grout Sea <br /> I aI Cathodic Protectil n Rotary Type of Grout <br /> Disposal Other Other, Informatibn <br /> .[. Geophysical S Sur°face-Seal: In5ta. -led b <br />� PUMPIINSTALLATION: Contractor <br /> Type of Pump . ^ H.P. <br /> PUMPIREPLACEMENT: Q State Work Done <br />' <br /> GPUMP I REPAIR: pState Work Done <br /> F. Approximate Depth <br /> DESTRUCTION OF.WELL Well Diameter <br /> D Id allte <br /> �-yr 14 .,escri be Materia ars Proceduee - <br /> danc <br /> iI hereby certify thatIlhave_ prepared this application and !that the work. will be done in accor0 <br /> fwith'� San Joaquin Couniy br'dinances, 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 trlk he W for which th.i s 'permit is i s sued,. I shall <br /> not employ any person in such manner as to; become subject to Workman's Compensation <br /> i aws of Cal i forn is.;' W ` <br /> ' I WILL CAL FOR A O . I P TION -PRIOR TO GROUTING.AND A FINAL INSPECTION. t <br /> ISIGNED TITLE: DATE: <br /> IM iIDRAW PLOT PL N ON REV SIDE <br /> R DEP RTMENT USE ONLY <br /> PHASE I ,� DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDiTIONAL COMMENTS: ` <br /> PHASE. 1f. GROUT; INSPECTION PHASE I AL INSPECTION <br /> [INSPECTION 8 • I� DATE INSPECTION BY DATE 5- l��"v. <br /> - r. , 2M <br />