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JOAQUIa L CAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 . Hazelton Ave. , StocktMrr,GA m <br /> . .05 Perit No. 79- 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> (Canplete In Triplicate) <br /> Application is hereby made to ,the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulat.iohs of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS / Ln 4 CITY/TOWNAC'� .� <br /> Owner's Name u c Phone C� ,S <br /> City <br /> Address 32b U <br /> Contractor' s Name - IJ f LicenseN Phone _ <br /> IS CERTIFICATE OF WOPY'SAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES a/ NO C <br /> C <br /> TYPE OF WORK (Check) : NEW WELL191 DEEPEN O RECONDITION O DESTRUCTION❑ r <br /> WELL CHLORINATION 0WELL ABANDONMENT O OTHER ❑ <br /> PUMP INSTALLATION JR ' PUMP REPAIR O PUMP REPLACEMENT p 7C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY li <br /> SEWAGE DISPOSAL FIELD SSPOOL/SEEPAGE PIT OTHER 6r <br /> PROPERTY LINE - PRIVATE DOMr STIC 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 h <br /> Domestic/public Driven , Gauge of Casing '1 e IQ) <br /> Irrigation : Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection Rotary Type of Grout�<Mr-Arf <br /> i Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> O <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1 14 H. <br /> i PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: OState Work Done <br /> 1 <br /> DESTRUCTION OF WELL : Well Diameter Approximate Depth <br /> II Describe Material and Procedure <br /> — <br /> I hereby certify that I have prepared this application and that the work will be done in accorda, <br /> with San Joaquin County Ordinances., State Laws, and Rules and Regulations of the San Joaquin Loc <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 a5 to become subject to Workman's Compensation <br /> laws of California . " <br /> I WI CA�IORGN TION PRIOR TO, GROUTING AND FINAL INSPECTION.TITLE: DATE: 7SIGNEDDR W. L L ON RE SIDE <br /> FOR PARTMENT USE LY <br /> APPLICATION ACCEPTED BY / �C/� DATE 7 <br /> PDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> R <br /> ,� <br /> INSPECTION BY <br /> DATE hr INSP—EFCTION BY C • DATE 5/19 2P <br /> "tI i n 1�c D--.. Q /7Q Q A-t A) o.!fi'N✓Y�f'v /Q f.�00 tr�aR-L <br />