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SAN J0AQU1N LUCAL" HLALIH U1SIK1L1 _ <br /> FF ICE USE: 1601 E. Hazelton Ave. ,=-Stocikton, CA 95206 Permit No. <br /> " 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 is hereby made to 'the San Joaquin Local Health District fora permit to, construct <br /> and/or install the work hereinldescribed: : This application is made incompliance with- San <br /> Joaquin County Ordinance No. 1862 and the -Rules and . Regulations of the ..San Joaquin Local . Hea,lth <br /> District. <br /> EXACT_STREET ADDRESSc J j f CITY TOWN <br /> l <br /> Owner's Name ;� Photle_�7�j� <br /> Address I' <br /> Contractor' s Name 4 ttfoa-6 r e. License# ung/. Phone_ <br /> IS CERT-ITICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE. WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ * <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E3 OTHER 0 NJ <br /> PUMP INSTALLATION. D PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTICJTANK /ODS SEWER LINES PIT PRIVY , <br /> SEWAGE iDISPOSAL FIELDf CESSPOOL/SEEPAGE PIT 0THER10Czz--410 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE fTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I <br /> Industrial Cable Tool Dia. of Well Excavation / <br /> `Domestic/private I Drilled Dia. of Well Casing <br /> .Domestic/public I Driven Gauge of Casing <br /> Irrigation i_Gravel Pack Depth of Grout Seal- <br /> Cathodic Protection" Rotary Type of Grout <br /> Disposal I Other Other Information r <br /> Geophysical j Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type ofIPump J.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: _ QStat'e _Work Done_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work .will be done in accordance <br /> Mith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> health District. Home owner o'r' 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. " r <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED [ TITLE: DATE:' <br /> (DRAW PLOT P N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY f <br /> 1HASE I <br /> FPPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS : <br /> PHAg II GROUT INSPECTION PHASE WI FINAL INSPECTION <br /> NSPECTION BY DATE A 4r 7g ,INSPECTION BY DATE <br />;H .1-426 Rav_ 12-77 /0224/ 1 /- rr <br />