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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> S CA 95205 Permit No. '��Z <br /> EQR OFFICE USE: 1601 E. HazeltonAye. , tockton, <br /> Telephone: (209) 466-6781 Date Issued 7-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires. l Year From Date Issued ; <br /> IN <br /> Complete In Triplicate <br /> a. uct <br /> Application is hereby made tol�the San Joaquin Local Health .D stmade iict orcampei permit <br /> and/or install the work herertn; described. This applRegulan <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health <br /> District. CITY/TOWN <br /> EXACT STREET ADDRESS (0 41 Phone <br /> Owner's Name G� A <br /> City <br /> Address: c /��:►^ 4 <br /> License S . Phone ��-��}s� <br />' Contractor' s Name <br /> IS CERTIFICATE OF. IJORKFiAN'S COMPENSATIO'! I{1SURAt10E 0 FILE WIT I SJLHD? YES NO <br /> TYPE OF WORK ('Cheek} ` -NE <br /> WEL—co❑ DEEPEN [3-- RECONaI7I0N [� DESTRUCTION NO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ - <br /> PUMP INSTALLATION)! PUMP REPAIR❑ 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 WELL44 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Other' Other Information <br /> r Surface Seal Installed by: <br /> Geophysical <br /> PUMP INSTALLATION: Contractor / `� <br /> Type of Pump x, - r 'd H.P. <br /> PUMP REPLACEMENT: E]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well- Diameter - =� - -Approximate Depth ;L . <br /> ��-�-- <br /> Describe Materia an Procedure <br /> work will be done in actor ant <br /> 1.I hereby certify that I have prepared this application and that the <br /> f with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner <br /> 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: _ <br /> SIGNED DRAW PLOT _LTN_ <br /> ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 4 PHASE I DATE '.Sr' <br /> f APPLICATION ACCEPTED: BY.° � <br /> i ADDITIONAL COMMENTS : x PHASE III FINA INSPECTION <br /> T <br /> k PHASE II GROUTiINSPECTION <br /> INSPECTION BY ' DATE INSPECTION BY DATE <br />