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ee Iry <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FICE USE: /1601 E. Hazelton.Ave. , CA 95205 Permit No. -/ dµ <br /> Telephone: (209) 466-6781 <br /> w APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - <br /> z: <br /> This Permit Expires 1 Year From Date Issued ' : <br /> Complete In Triplicate F <br /> Application is Hereby made to the San Joaquin Local Health District -for,-a permit to -construct f <br /> and/pr install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health <br /> District. _ <br /> EXACT STREET ADDRESS .D /V 1197 CITY/TOWN <br /> Owner's Name Phone <br /> Address City ' <br /> Contractor' s Name, License#,f3 ?,YL Phone <br /> IS CERTIFICATE OF WORKMIAN'S CO"i SA I0;! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN Cl' RECONDITION [] DESTRUCTION❑ _ r <br /> WELL CHLORINATION D WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION EJ PUMP REPAIR 0 PUMP REPLACEMENT G <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 R TYPE OF WELL CONSTRUCTION SPECIFICATIONS k <br /> Industrial I 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 F Rotary Type of Grout F <br /> Disposal Other Other Information <br /> Geophysical n Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> �l" � <br /> Type of Pump ri H.P. <br /> PUMP' REPLACEMENT: FState Work Done. J��� . - ✓ .�^ _ 00,116 <br /> PUMP REPAIR: Q State Work Done <br /> I-DESTRUCTION OF-.WELL.:,_-Well-.Diameter T - - _ Approximate-Depth -- - - <br /> Describe Material an2 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 /> 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 INSPECTIO TO-)ROUTING AND A FINAL INSPECTION. <br /> - <br /> SIGNED DATE: <br /> f� ' <br /> =- ..._._ <br /> JD58W PLOT- PLAN 0 EVERSE SIDE) <br /> ' <br />� FOR D PARTM T USE ONLY <br />� PHAS.E I � . <br />° APPLICATION ACCEPTED BY DATE Olc�5_1_7 00 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />` INSPECTION BY ' DATE INSPECTION BY ge DATE <br /> ru IAOC 0,,.. 10_'77 1/78 ZM f. <br />