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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit Na. - 7 <br /> Fog FFICE USE. 1601 E. TelephoneAve�209)o�6fi-678IA 95205 <br /> Date Issued a-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. <br /> This Permit Ex ires 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 /> pp. This <br />' and/or in the work herein described. Rules apndlicatio is, mafetin Sanpli <br /> :Joaqu-anc�nwLncalith aHealth <br /> 'oanu�n County prdinance .�o. ..��862 and t - <br /> �istrct. <br /> EXACT STREET ADDRESSa 9 CITY/TOWN <br /> � <br /> Owner' s Name a Phone <br /> City .�i�rl.�. — <br /> Address <br /> Contractor' s Name <br /> ' Li cense#fig S� Phone ��^��1 �— <br /> IS CERTIFICATE OF WORKMAN'S COIrIP-_NSATION IidSURAIaCE ON FILE WITH SJLHD? YES X AVO <br /> TYPE .OF WORK Check) : NEW WELL D DEEPEN [ 1 RECONDITION Q DESTRUCTION[1 <br /> 3 WELL CHLORINATION p WELL ABANDONMENT 0 MP REFER 0 ENT Cl G <br /> PUMP INSTALLATION PUMP REPAIR[ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> CESSPOOL/SEEPAGEPRIVY <br /> PIT OTHER <br /> SEWAGE DISPOS AL FIELD <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ---�- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ti Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor R H.P. <br /> Type !of Pump <br /> JPUMP REPLACEMENT: jI State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well :Diameter. Approximate Depth <br /> { Describe Materia and Procedure <br /> II hereby certify that I have prepared this application and that the work will be` done in accnrdan <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the ?San Joaquin Loca <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. "' <br /> ;I WILL CALL A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL ;4NSPECTION. <br /> SIGNED TITLE: DATE: -2 1�7 <br /> DRAW PLOT PL N ON REVER E SIDE <br /> FOR DEPARTMENT USE QNLY <br /> PHASE I DATE ZZ <br /> 3APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION PHASE III FINAL INSPECTION <br /> � <br /> INSPECTION BY DATE INSPECTION BY DATA= o�� <br />