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SAN JUAQUIN L�IGAL r.MAL 141 U1J I KIL I <br /> k <br /> FFICE USE: 1601 E. Hazelton Ave.` S,toc,kton, CA 95205 Permit No. "2�-4zy <br /> t Telephone: ' (209) 466-6781 <br /> '+APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This -Permit Ex ires "1 Year From Date Issued <br /> 'Complete In Triplicate <br /> Application i's 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 />,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin. Local Health <br /> Cistrict. <br /> EXACT STREET ADDRESS CITY/TOWN , z<a� � a�, <br /> Owner's Name <br /> Phone i <br /> Address t City,, foo k4al. <br /> Contractor' s Name „�, License / Phone <br /> ?S CERTIFICATE OF WORKMAN'S COMPENSATION INSURAN Qfl FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW W£LL CI DEEPEN RECONDITION ❑ DESTRUCTIONE] <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER Q <br /> PUMP INSTALLATION 0 PUMP REPAIR Q PUMP REPLACEMENT Q 4 <br /> DISTANCE TO NEAREST: SEPTIC STANK/60 7-E SEWER LINES/per-{ PIT PRIVY ---- <br /> SEWAGE DISPOSAL FIELD/De),/4-. CES—SPO L/SEEPAGE PIT -� OTHER ---- <br /> PROPERTY LINW4PRIVATESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation „u <br /> Domestic/private I Drilled Dia. of Well Casing l; _ <br /> r <br /> Domestic/public I Driven Gauge of CasinZ,2 q4 <br /> g <br /> Irrigation i Gravel Pack Depth of Grout Sea <br /> Cathodic Protection I Rotary . 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical v . _ Surface Seal Installed by:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well D'ilameter 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 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 i <br /> . not <br /> of California." <br /> I WILL CALL FOR A G UT NSP T N PRIOR TO GROUTING AND A FINAL INSPECTION. r <br /> SIGNED TITLE: DATE:' v <br /> Y -22 494V-1 <br /> DRAW T PLTN ON REVERS IDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY „� DAT_E <br /> ADDITIONAL COMMENTS: ' l <br /> _ PHASE. II_GROUT INSPECTION PH AL INSPECTION <br /> INSPECTION BY DATE T INSPECTION By <br /> DATE <br /> EH 1426 Rev_ 12--77 1/78 2M <br />