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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Qr USE: 1601 E. Hazelton Ave. ,-�StdcRton, CA 95205 Permit No.z <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Date Issued S-/�- . <br /> This Permit Expire S 1 Year From Date Issued <br /> Compl ete In Tri pl icate <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 /> roanunCounty Ordinance No. 186'2 and tie Rules and Regulations of the San Joaquin Local Health <br /> District. _ <br /> EXACT, STREET ADDRESS 1 Al - CITY/TOWN <br /> iOwner' s Name Phone <br /> Address / City <br /> Contractor's Name censPhoned L � <br /> ` IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURANCE^'ON FILE WITH SJLHD? YES 11,10 <br /> TYPE OF WORKCheck <br /> � ) NEW WELL L�"' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTAiLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK/ EWER 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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f/ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Y Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea] <br /> Cathodic Protection �k Rotary Type of Grout J , <br /> Disposal Other Other .Information <br /> Geophysical Surface ;Seal Instal,-led �.- <br /> PUMP INSTALLATION: Contractor J „ _ <br /> Type of Pump H, . f <br /> PUMP REPLACEMENT: Q State Work Done <br /> i <br /> RUMP REPAIR:�Ym _ _❑Sta.te_Work_ Done_ <br />'. DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia 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 such manner as to become subject to Workman's Compensation <br /> laws of California.''" <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: 5 <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />;APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL- COMMENTS. <br /> PHASE II GROUT INSPECTION PHA E III INAL INSPECTION <br /> INSPECTION BY DATEsr INSPECTION BY DATE -d�-�S-?9 <br /> i <br /> ° <br /> SEH 1426 Reu_ 12.-77 __ T /-7 Q IM <br />