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V JUAQU1N LUUAL HtALIF' U1�.IKMI permit No. /lis <br /> FFICE USE: 1601 Telephone:Hazelton ie o9�o466-6781A 9� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _ -7 <br /> This Permit Ex fres 1_Year Date Issued <br /> Complete In Triplicate <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San <br /> nuin County Ordinance ":u. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> trict. <br /> .CT STREET ADDRESS �" -;rte CITY/TOWN <br /> er' s Name v Phonez� « <br /> ress <br /> tractor's Name [12 License; /L ©� Phone--2-0;-c/ ly <br /> - 41z <br /> CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE Oil FILE 41ITH SJLHD? YES t40 <br /> 'E OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION 0 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C'1-''PUMP REPAIRED PUMP REPLACEMENT 0 <br /> >TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (� 1 <br /> PROPERTY LINE PRIVATE DOMESTIC ' =' L PUBLIC DOMESTIC WELL `FJ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 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 /> Disposal —"t er Other Information <br /> Geophysical urface Se Installed by: <br /> NP INSTALLATION: Contract ,-� Y� �� ' <br /> Type of Pump H'p <br /> MP REPLACEMENT: [] State Work Done <br /> MP REPAIR: ❑State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordan( <br /> th San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca- <br /> alth 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 L <br /> not employ any person in such manner as to become subject to Workman's Compensation �J <br /> laws of ifornia." <br /> WILL CAL �FR GR UT INSPE PRIG TO GROUTING AN FINAL INSPECTION. <br /> GNED TITLE' DAT&- <br /> D PL T PLAN ON RE IDE <br /> FOR EP RTMENT SE ONLY ,� <br /> IASE I DATE B 9' <br /> PLIC{ TION ACCEPTED BY �Y� • �` <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ISPECTION BY DATE INSPECTION BY r i DATE 6-/y:2f <br /> G� ti�LY� 1/78 2M <br />