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SAN JOAQUIN LOCAL HEAL 1 H Ul!) iLl <br /> IQR FFICE USE: 1601 E. Hazelton Ave. , Stocittori, CA 95205 Permit No. <br /> Telephone: (209)"466-6781 F <br /> Date Issued 4 <br /> EL <br /> APPLICATION FOR WL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires1• Year From Date Issued <br /> .,, Complete In Tr.i pl i tate ©13_® -C --/3 <br /> C& <br /> Application is. hereby .made to the San Joaquin Local Wealth 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 RulesF3and .Regulations of the San Joaquin Local Health <br /> District. /ODS aV6' Dgv,-S P-D4 <br /> #1 CITY/TOWN 40,0/I <br /> EXACT STREET ADDRESS MI` S 4F -.9oRe/ <br /> Owner's Name WAW.0 a `5�7' Phone 4& S <br /> Address 37 ` Lc: Ci ty - nz <br /> Contractor's Named IIU�'c� Li cense#� 70ZRhone :75I—337_��.. <br /> IS CERTI_FICA_TE_OF_ _�O.f Kt1AN'$__CSO"1PENSAT_IQ��I 3SURAIrICE 4tl_FILE- 117I .I__SJLHD? _ .YES _ __ .NO__ ,q <br /> TYPE OF WORC�Check _- NEV WELD DEEPEN--O-- R�CO�ND17TON-0 DESTRUCTTON[]�`" —� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 o <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [] � <br /> DISTANCE TO NEAREST: SEPTIC TANK 3oW SEWER LINES 3-4-0 PIT PRIVY �-- <br /> SEWAGE DISPOSAL FIELD --6 SPOOL/SEEPAGE PIT ::-f THER � <br /> PROPERTY LINE PRIVATE DOMESTIC WELL --I� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ____ <br /> `7sX Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ <br /> /Irrigation Gravel Pack Depth of Grout Seal .4-e- <br /> V Cathodic Protection Rotary Type of Grout_q 50e� s,2��-2'_ <br /> Disposal ' Other Other Information _ <br /> Geophysical Surface <br /> f. a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br />. PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />-DESTRUCTION-OF WELL':-,%AWell,4'D7'ameter- - T "` �-Apftoxim te"Depth � <br /> f Describe Materia an Proce ure <br /> I hereby certify that I have prepared this a plication 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 />' vA <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND -A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: lv- ZS 7 <br /> DR W PL T P N ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I DATE f <br /> APPLICATION ACCEPTED BY 64::1Z& <br /> ADDITIONAL`'-C'bMMENTS : <br /> PHASE II GROUT INSPECTION- PHASE III FINAL INSPECTION <br /> :d <br /> IN ECTI01N.n.eY DATE INSPECTION BY [� v _ DATE z7 77 <br /> Cu inns na„ 19_77 7$ 2M..: <br />