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SAN JOAQUIN LOCAL-HEALTH -DISTRICT <br /> 'tock�ton, CA 95205 Permit No,22 -/z S? _ <br /> FORr-OFFIC1 USE: 1601 E. Hazelton Telephone: (209) 4664781 <br /> Issu <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date ed <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for <br /> capermit <br /> to conwithstruct <br /> and/or install -the work herein described. This application is made amp <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of .the .San Joaquin Local Health <br /> e <br /> District. CITY/TOWN � <br /> EXACT STREET ADDRESS �{ <br /> Phone - <br /> Owner' s Name <br /> AddressCity• <br /> Contractor's Name License# / PhoneT <br /> I5 CERTIFICATE OF WORK�1At1Is O"RFENSATIO"J INSURA`IN,'F ON FILE WITH SJLHNO <br /> D? YES <br /> _ r <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN ❑ RECONDITION ❑ <br /> DESTRUCTION❑ 5 <br /> WELL CHL INATION ❑ WELL ABANDONMENT.❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP ,REPAIR 0 PUMP REPLACEMENT (] <br />'r DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEP�BLIC DOMEOSTICTHERWE � <br /> PROPERTY LINE -. PRI'VAT DOMESTIC WELL ---- <br /> INTENDED USE TYPE OFWELL CONSTRUCTION SPECIFICATIONS <br /> fi <br /> Industrial Cable�Tool Dia. of' <br /> Well Excavation f <br /> . of Well Casing <br /> �.-Domestic/private Drilled k �{ DiaE — <br /> Domestic/public Driven r Gauge of Casing f <br /> Irrigation Grayel Pack.,; Depth of` GroutSeal <br /> Cathodic ProtectionRotary. Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface !Seal Installe <br /> PUMP INSTALLATION: Contractor H <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> jyI hereby certify that I have prepared this application <br /> and that the work will be done in accordant <br /> wwith 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 <br /> laws of California." <br /> I WILL CALL FOR A GROUT SPECTION PRIOR GRDUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: C <br /> " SIGNED DKAW PL T PL ON REVER S DE <br /> DEPA TMENT USE ONLY <br /> 1 PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> i <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BVi✓ 9 �7 <br /> '- - - _ 1 "_ �/wvti �'► �"` _/Z) <br /> f- � r"- 1 117 8 21_ <br />