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r SAN JOAQUIN LOCAL'-HEALTH DISTRICTFQS FFICE USE: 1601 E. Hazelton Ave. , ? 7,F <br /> St CA 95205 Permit No. <br /> ockton, <br /> Telephone: (209)..466-678 ,te Issued" -1 -� <br /> APPLICATION FOR WELL CONSTRUC <br /> (Eomp l ete I n 'Tr,,*' t0ft 13 IT9 <br /> Application is hereby made to the San Joaquin Local Health --District fo.r. a permit to construct <br /> and/or-,install the work herein' described.. This applica 4o" B <br /> Ww P <br /> ance withfSan <br /> Joaquin County Ordinance No. 1862 and the Rules and Regul on Joaquin Local Health <br /> District. / - : , •- <br /> EXACT"STREET ADDRESS a S C) G " ` %CITY/TOWN <br /> . ,i Phone <br /> Owner's Name <br /> Address _ .f City c I r <br /> Contractor's Name License Phone, f <br /> --- <br /> IS CERTIFICATE -OF WORKMAN`S=CO'clPENSAT16H INSU ANCE ON FILE WITH SJLHD? YES 0. <br /> TYPE 0 WORK-(Check)':- NEW WELL1� DEEPEN El RECONDITION [ ',.t.DESTRUCTION(n-.-„ .'R <br /> - WELL CHLORINATION G WELL ABANDONMENT PUMP REPLACEMENT OTHER Q. <br /> PUMP INSTALLATION. 0 PUMP REPAIR 0 <br /> DISTANCE TO NEAREST: SEPTIC'TANY0SAL2FIELD)2jQ(t MR LINE FIT PRIVY;- �O <br /> ` f SEWAGE DIS5P OL/SEEPh•GE PIS—�--OTHERPROPERTY LINVQ' RIVATTEDOM_ESTIG WELD PUBLIC DOMESTIC WELL =S - 0 <br /> INTENDED USE ' TYPE OF WELL ' } CONSTRUCTION SPECIFICATIONS <br /> iL industrial - Cable�Too1 "M"""` <br /> Dia. of Wel Excavation ` <br /> rivate Drilled of Well Casing <br /> Domestic/p Dia. <br /> Domestic/public Gauge of Casing_,/.�s <br /> Irrigation Gravel Pack Depth 'of Grout Sea �<�,,ni <br /> Cathodi c ProtectionRotary Type of Grout _ <br /> Disposal Other Other Information <br /> -. Geophysical . Surface Seal Insta e-d <br /> PUMP INSTALLATION: Contractor- <br /> T of Pump H. . <br /> 1 <br /> Type <br /> �PUMP REPLACEMENT: CjState Work Done <br /> `PUMP REPAIR: Q State Work Done . } <br /> f'D.ESTRUCTION OF WELL: Well Diameter Approximate Depth -� <br /> Describe Materia an Proce ure _ <br /> [ I hereby certify that -I have prepared this application and that the work will be done in accordant <br /> `with San Joaquin County Ordinances , State Laws , and. 'Rules' and Regulations of the-.San Joaqu.in 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 F <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 OUT NSION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> PLOT ON. REVER SI <br /> f FOR PEPAUTMENT USE ONLY <br /> !PHASE 1_r DATE /3cfU� <br /> AnPLICATION ACCEPTED BY �^^ <br /> :ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION PHASE III FINA INSPECTION <br /> INSPECTION BYI PECTI N B ATE g M <br /> FH 14 '26 ev. 9/78 - <br />