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r If SAN JOAQUIN LOCAL HEALTH DISTRICI <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , S.tocktbn`,'.'CA 95205 Permit No. 7g�/hsif _ <br /> Telephoner (209) 466-6781 <br /> IssuedII-JFK <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date <br /> // <br /> This Permit , ires 1 Year From. Date I*ssped. A <br /> '5.oja-fib Complete, In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or i nstal 1 'the wor'k!l.herel n described. This application is made in compliance with San =i <br /> �oanu» 'County Odi-nance ,'.ci. '1862 and the Rules and Regulations of the San Joaquin, Local He:alth. <br /> � <br /> District. �� �j� <br /> r`^I CITY/TOWN <br /> EXACT STREET ADDRESS F <br /> Owner's Name Phone <br /> Address f City . <br /> Contractor's Name E <br /> License# /6.fJ' 3 Phone U64 �s <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'J INSURANCE OM FILE, WITH SJLHO? YES <br /> TYPE OF WORK (Check) : ANEW WELLM DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLOR WELL ABANDONMENT EJ- ,. 'O'THER <br /> CHLORINATION Q <br /> PUMP INSTALLATION ❑ PUMP REPAIRf4 PUMP REPLACEMENT p <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 WELL <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 /> Iomestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor H.P <br /> Type of Pump <br /> [PUMP REPLACEMENT: ❑ State Work Done <br /> I IN <br /> PUMP REPAIR: : ❑State Work Done <br /> IDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure, <br /> ki hereby certify that I have prepared this applica-tion and that 'the'work will -be done 'in accordan <br /> with San Joaquin County Ordinances , State Laws , arid' Rules a•nd _Regulat'i ons of the San Joaqu'i n Loca <br /> $Health District. Home;jowner or licensed agents signature certifies the following: <br /> "I certify that in the performance of the work for''�whilch this permit is issued, I sha11 <br /> not employ any person in such manner ,a's toabecome �subject to Workman's Compensation <br /> laws of Californiall " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING`AND A FINAL INSPECTION. " <br /> W DATE: / 2� <br /> ,SIGNED TITLE: <br /> _ _(DRAW PLOT PLAN.- ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY � w <br /> PHASE I <br /> ,APPLICATION ACCEPTED BY - DATE ' 2� <br /> ADDITIONAL COMMENTS:.1 <br /> PHASE II GROUT INSPECTION PHA F AL INSPECTION <br /> 'INSPECTION BY IN. DATE ...INSPECTION B DATE _f_-49 �cf2- <br /> Fu 1Q7r, R <br /> a„ ° 19W77. .,p .. _ ... � 78 2M <br />