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IZ1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 10E USE: E. Hazelton Ave. , .Stocktoo, CA 95205 Permit No. 7 _//,31111, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-7-/-]�' <br /> This. Permit Ex ices .l. 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 /> land/or install the work herein described. This application is made in compliance with San <br /> k ,oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> k District. <br /> EXACT''STREET ADDRESS 919 CITY/TOWN_ �l <br /> Owner' s Name J �� ; Phone <br /> Address .D l/ ' c� r _ City: Q'-ye <br /> Contractor' s Name �` „P/ j License#,/U 2-.,d Phone <br /> IS CERTIFICATE OF WORKMAN'S COmPASATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL, ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIREK PUMP REPLACEMENT ❑ <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 WELL CONSTRUCTION U ION SPEGIFICATION5 <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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> P Other Other Information <br /> Geophysical Surface Seal Installed b : r <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H. 1 <br /> PUMP REPLACEMENT: <br /> []State Work Done <br />' PUMP REPAIR: (State Work Done7. <br />'DESTRUCTION OF WELL: Well Diameter rF` <br /> Approximate 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 JoaquinLocal <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 INSPECT N P IOR�O GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: _ DATE: 7 nx <br /> D W PL T P W, ON REVERSE SIDE <br /> . FOR DEPARTMEIT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE I I F AL INSPECTION � <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12=77 <br />