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SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazel-ton -Av'e.-�kton, CA 95205 Permit No. r-IRZ ff <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued i„_,� <br /> This Permit Expires 1 Year `From Date Issued , <br /> Complete In Triplicate ' <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 /> Joaqui'n' County Ordinance No. ,1862 and the Rules and- Regulations of. the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS d JT CZtA, CITY%TOWNf c�f <br /> Owner's Name - c°' �/ -- Q d f D r Phone 77 _3 <br /> I �' ,cam <br /> :Address. C. f . City <br /> Contractor' s Namee71- 7— W1 l License Q' Phone - ,Z Z 5e <br /> IS CERTIFICATE OF WORKtiAN'S CO"1PENSATIO�f INSURANCE ON FILE WITH SJLHD? YES 1140 f� <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC TANK ,--�—�— SEWER LINES J'70 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialyCable Tool Dia. of Well Excavation <br /> `Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing 1,2— <br /> Irrigation <br /> ,ZIrrigation w Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout !ZX-1,E-Cy- <br /> Disposal <br /> c <br /> E Disposal r Other Other Information <br /> Geophysical _ Surface Seal Instal I ed b ti f <br /> PUMP INSTALLATION: Contractor ,r i <br /> - Type -of Pumo N.P. <br /> Iw <br /> PUMP REPLACEMENT: State Work Done <br />' PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Procedure r <br /> t I f <br /> I hereby certify .that I have prepared this application and that the/work will be done in accordanc{ <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: 4 <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> hot employ any person in such manner as to become subject to Workman' s Compensation if <br /> laws of California. " r <br /> I WILL CALL FOR A GENT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />` <br /> DATE:/N- <br /> 7SIGNED TITLE: <br /> (DRAW PLOT PLAN ON REVERSE -SIDE) �~ <br /> FOR D ARTMENT USE ONLY , <br /> f PHASE I <br /> APPLICATION ACCEPTED BY _.f DATE <br /> ADDITIONAL COMMENTS. <br /> PHASEI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �0- INSPECTION BY DATE <br /> k r. <br />