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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FFICE USE: 1bQ1 E. Iiazelton Ave. , tockton, <br /> S GA 95205 FDate <br /> t No. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued <br /> This Permit Expires 1 Year From Date Issued <br /> ' Complete In Tri—plicate); <br /> Application is hereby made t the 5ar�` Joaquin Local Health District fora permit t <br /> and/or install the work herein described. This application is made in compliance withSanJoaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin -Local Health <br /> District. <br /> EXACT STREET ADDRESS a CITY/TOWN •�U- ' <br /> Owner's Name <br /> Phone <br /> Address City. �. <br /> Contractor's Name License# 4 2 ? Phone 3 ?—J73 C <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL R DEEPEN 0 RECONDITION rl DESTRUCTION[] 4: <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER n �0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT E <br /> DISTANCE TO NEAREST: SEPTIC "TANK 4S-1 SEWER LINES /c*o/- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE <br /> PROPERTY LINE -, PRIVATE DOMESTIC. WELL PUBLIC DOMESTICWELLy H <br /> ` <br /> — INTENDED USE TYPE OF WELL { <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation lD , <br /> Z_Domestic/private Drilled Dia. of Well Casing 6f� <br /> Domestic/public Driven Gauge of Casing /1 r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �( Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , E <br /> PUMP REPLACEMENT: (State Work e <br /> PUMP REPAIR: ❑State Work Done <br /> _ 1 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approro <br /> ximate Depth <br /> Describe Material and Procedure <br /> I 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 suchmanner as to become subject to Workman 's Compensation <br /> laws of alifornia. " <br /> I WILL CAL ' OR GR( INSPECTI PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED Q <br /> TITLE: DATE: '7•b ., <br /> DRAW PLOT PLTN ON REVERSE IDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> tf 7. DATE <br /> 4DDITIONAL COMMENTS: ,� <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTiO <br /> INSPECTION BY DATE r <br /> INSPECTION BY DATE 7f <br /> 7H 1426 Rav 19-77 _ <br />