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t.. <br /> SAr, JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: f -4� tockton, CA 95205 Permit No. 75-�.5�'_ <br /> •� � 1601 E. Hazelton--. Ave.A <br /> Telephone: ., T209) 466-67.81 Date Issued �-1 D-79 <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 /> and/or install the work herein described'. , This applicationinsmoof the San Joaqui-nwLocala <br /> iHealthT <br /> 1.eaQuin County Ordinance "�o. I1862� and the Rules and Regulat a <br /> Distract. <br /> CITY/TOWN <br /> EXACT STREET ADDRESS -!�% _ - -- <br /> Phone <br /> Owner' s Name <br /> Address. :3 ` City <br /> Contractor's Nam f License Phone <br /> IS CERTIFICATE OF WORKMAN COMPENSATION IPaS RANCE ON FILE-WITH-SJLND? YES <br /> TYPE OF WORK (Check) : NEW WELLS� DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ S <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY_ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELt�' - <br /> =--CONSTRUCTION SPECIFICATIONS <br /> Industrial 5B18 Tool Dia. of Well Excavation S <br /> �mestic/private Drilled-, Dia-. of .Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal - ' <br /> Cathodic Protection c�otary .. Type..of.-Grout° <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal e <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type' of Pump <br /> jPUMP REPLACEMENT: State Work Done <br /> I <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: WelliDiameter Approximate Depth <br /> Describe Materia an Procedure <br /> I _ <br /> � I hereby certify that I have`Fprepared this application and that the work will be done in accordar <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loci <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 /> k not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." I <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> . SIGNED <br /> TITLE: DATE <br /> : <br /> (DRAW PLOT PLAN ON REVERSE S DE <br /> FOR DEPARTMENT USE ONLY /— <br /> PHASE I DATE T <br /> APPLICATION ACCEPTED BY T ' <br /> ` ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY C. ATE <br /> n '7'7 <br />