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® SAN JOAQUIN LOCAL HEALTH DISTRICT —7 Permit No.�� 'l/3 <br /> Fog FF CE USE: 1601 E. Hazelton- Ave. ,. Stockto <br /> Telephone: . .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued_�-7 7 <br /> This Permit Ex ices I ..Year From Date Issued <br /> Complete In Tri.pTicate <br /> Appliclation is hereby made to the San Joaquin Local -,Health District iroirca permit compliance with construct <br /> and/or install the work herein" described. This application is <br /> made loanuin County Ordinance No. ,1862 and the Rules and -Regulations -of the.—,San—Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS I <br /> / 1� �c� CITY/TOWN [��rs 1a-a � <br /> Phone <br /> Owner' s Name <br /> Address City/ kJ . <br /> Contractor' s Name - / Liceems% <br /> hone <br /> IS CERTIFICATE OF WORKMAN'S COMP SATI I] INSURANCE ON FILE WITH SJLHD? YES N0� <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q DTH ER f� <br /> PUMP INSTALLATION N PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C'�1 <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 Sea, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor L� �� <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP R@PA44r; State Work Done <br /> DESTRUCTION .OF WELL:,, Well Diameter Approximate Depth <br /> Describe Materia ,an Procedure <br /> , I hereby certify r that I have prepared this application and that the work will be done in accordant <br /> { <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 INSPECTION PRIOR T GRDCJ G AND A FINAL IJVSPECTION. <br /> rl f DATE: <br /> SIGNED DR PLOT PL N ON REVERS SIDE <br /> t v FOR DEPARTMENT USE ONLY <br /> PHASE I b,(� DATE '1 <br /> (APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> 1INSPECTION BY DATE INSPECTION BY <br /> .1 /78 ...2M <br />