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SAN JOAQUIN'LOGAL HEALTH DISTRICT permit No. �S7Q <br /> FFICE USE; 1601 E. Hazelton Ave. , Stuckton, GA 95205 <br /> Fog 209) 466-67Bf 4 -- <br /> I Telephone: ( <br /> i Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres I Year From Date Issued <br /> Complete In Triplicate <br /> mit <br /> Application is hereby made to ! <br /> the Joaquin Local Health District ,for a .peiancetwithnSanuct <br /> and/or install the work herei.n�862sandbthe Rules anndlRegulations,ofein the-SanpJoaquin Local Health <br />.'.oanu i n County Crdi nance No . 1. <br /> C,istr�ct. CITY/TOWN <br /> EXACT STREET ADDRESS Phone; — <br /> Owner' s Name "` e7 <br /> City v+/ <br /> AddressPhone � 9 <br /> r License# a3 <br /> Contractor's Name t NO <br /> M � <br /> IS CERTIFICATE OF WORKMAN'S C PENSATIO"1 INSURANCE ON FILE WITH SJLHD? Y � <br /> ON ❑ DESTRUCTION O <br /> STYPE OF WORK (Check) : NEW WELL DEEPEN CI RECONDITIWELL ABANDONMENT a OTHER EI _. <br /> WELL CHLORINATION [1 <br /> PUMP INSTALLATION R! PUMP REPAIR[] PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_,Q SEWER LINES PIT PRIVY �- 5-0.1 OTHER - <br /> SEWAGE DISPOSAL FIELDESTiCPWaLLSEE ;PUBLIC DOMESTIC WE <br /> PROPERTY LINES PRIVATE <br /> } TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Excavation <br /> Industrial Cable Tool <br /> Domestic/private A Drilled Dia. of Well' Casing <br /> ✓- - . Gauge of Casing /�- <br /> Domestic/public Driven De th of Grout Seal D ' <br /> Irrigation Gravel Pack p <br /> L,/ Rotar <br /> Cathodic Protection y Type of Grouttion <br /> r Other Informa <br /> Disposal other ' <br /> Geophysical Surface Seal Installed b <br /> 4PUMP INSTALLATION: Contractor H..........p, <br /> Type jof Pump <br /> 1PUMP REPLACEMENT: []State Work Done <br /> ' PUMP REPAIR: Q State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: WellilDiameter and Proce ure <br /> Describe Materia <br /> k hereby certify that I have prepared this application and that the work will be done in accordan <br /> I y State Laws , and Rules and Regulations of the San Joaquin Loca <br /> with San Joaquin County Ordinances , <br /> Health District. Home owner or licensed agent's signature for cthisfpermiteisoissued�• I shall <br /> "I certify that in the performance of <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> rI WILL C R A GROUT I T •PRIOR TO GROUTING AND A NAL INSPECTION. DATE: <br /> TITLE: <br /> SIGNED LOT -AN ON REV <br /> j+ FO EPARTMENT USE 0 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED <br /> 1ADDITIONAL COMMENTS +` PHA II Al- INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION ATE <br /> !INSPECTION BY I DATE � <br /> lC v.��s wti� �Y.S�CUC {��gj7���� _ 1 78 .�2; <br />