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SAN:JOAGUIN'LIO}.rAL-,HE- ELTH DISTRICT <br /> OR USE: 1r.60L E. iTaze- on-�-Atiie -, St-bckton, CA ` 95205 Permit fVo.'Z <br /> Telephane:_­ (209) 4666781 <br /> _.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date IssuecL5_/-?g <br /> This:.Permit Ex ires 1, Year From Date Issued <br /> Complete 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 /> ,oaqu;n Count rdi ance .,re0. ,1862- and t Ru]ei aye Regulations- ofthe San Joaquin- Local ..Health <br /> District. <br /> r �7, �► �� (�/� '� <br /> EXACT SCREE ADDRE S-oZDUr� � lL..�afL�� !l�Q�LL—//xGLc� �, e CITY/TOWN <br /> Owner's Name �� - Phone <br /> Address City `7Gn '��.�� .. _ <br /> Contractor's Name License# Phonef7,z � <br /> IS CERTIFICATE OF WORKM 'S CbMPENSATION INSURANCE ON !FILE WITH SJLHD? YES )C NO <br />` TYPE OF WORK (Check) : NEW WELLDEEPEN d RECONDITION [] - DESTRUCTIONEJ <br />',N WELL CHL INATION a WELL ABANDONMENT 0 OTHER{ <br /> PUMP INSTALLATION EJ PUMP REPAIR❑ PUMP REPLACEMENT Q C <br />' DISTANCE TO NEAREST: SEPTIC TANK /an j SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS 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 /> I' _- ) ^Domestic/private Drilled , Dia. of Well Casing <br /> Domestic public Driven - Gauge of Casing j�p Baas <br />' Irrigation X Gravel Pack Depth of Grout Seal22 <br /> Cathodic Protection ��Rotary Type of Grout �� irf <br /> Disposal . Other Other Information <br /> IF Geophysical Surface Seal Instal le b <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [n State Work Done <br /> i <br />'PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL.: -"'Wel'T—D "ameter - '-" Appro imateTDepth -- --- <br /> t Describe Material and Procedure <br /> 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 /> 4Health 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 GRO INSPECTION PRIOR TO GROUTING AND A FIVL INSPECTION. <br /> iSIGNED TITLE: DATE: <br /> 17� <br /> DR W PLOT PVAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPS- L ICATION ACCEPTED BY DATE 2k--7f <br /> ADDITIONAL COMMENTS: Si <br /> PHASE II GROUT INSPECT 0 PHASE III FINAL INSPECT N <br /> INSPECTION BY DATE_:-3-?5 T INSPECTION BY DATE - -7 <br /> - 3 -99 <br /> FH 191;, you _1.2_77 f s _ �' J 1 /'7R 2M <br />