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SAN JOAQUIN LOCAL HEALTH DISTRICT i I <br /> OFFICE USE: 1601 E. Hazelton- Ave. , St;oc-loon, CA 95205 Permit No.7g- 7D _ <br /> i <br /> Telephone (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 7-27 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> fora permit to construct <br /> Application is hereby made to the San Joaquin Local Health District p <br /> and/or install the work herein described. This application is made in compliance with ,San <br /> Joaquin County Ordinance ado. 1862 and the. Rules and Regulations of the San Joaquin ,Local Health <br /> District. =:--�( <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phone92 <br /> me <br /> Address . <br /> City <br /> License# 3 sta I Phone$�,�-'7'�7� <br /> Contractor's Name -Iic <br /> S CERTIFICATE OF WORKMAN'S COMPENSATION IINSURAINCE. ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Cf RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION a WELL ABANDONMENT 0 OTHERt3 <br /> PUMP INSTALLATION;K _PUMP 6REPA°IR❑ - 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 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 /> 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 /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum _ -H.P..-.,_� <br /> PUMP REPLACEMENT: --- .--Q State-Work-D-ohe <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 /> f not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL FO UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ° Ole TITLE: DATE: <br /> DR W PLT PETN ON REVERSE SIDE <br /> OR DEPART ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />',ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION RASE III FINAL INSPECTION <br /> 1INSPECTION BY DATE INSPECTION BY <br />