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y FFL.CE 11SE SAN JOAQUIN:�JQCAL,)i �ALTH DISTRICT <br /> Ib01 E. Hazelto /eve J, . S ockton. CA 95205 Permit No. <br /> '�,- 'Telep��one,.- ,(Z09�:4�P-b781. 6 <br /> 1. <br /> APPLICATION FORYWELL CONSTRUCTION OR PUMP PERMIT �78' <br /> Tha's . <br /> Date Issued <br /> rrhi;t E eros �i tear'Frm Date I's'sud,_� <br /> ��;01 J1. �, - , CAmpl ete , r� Trl Cate �� � :l <br /> Application+ is h r <br /> ereby made to the San Joaqu3ni-Loca1�,7;Heal.th District ;for ,a }f <br /> and/ar, ins.tal t 4 #aer �vorlc here:i _ #ese;rib'ed Thls a 1:Icat. per;tnit_.�t �f construct y <br /> Joaquin Count ;. , pp i on .i s .,made, i n: ompl;iLanGe w tl . San <br /> y prd,irrance ]o..; I8b2, an:d tbe .:R l s ;arid,FRegulations af. tfae,San,,Joaqu?r� Jtha.t,,;Heal:th <br /> ^istriEt <br /> /3oo`E f- pF �Arsc�-F P.p <br /> k EXACT M"tt'7;/1D RF�SS� 4 /4i Zd?ZO:.t <br /> Owner's Name ;�` - C i TY/TOWN .1>� n <br /> Address <br /> ;101:�! _ Phone Sla <br /> Cit <br /> Contractor's Name _:. .. <br /> Li cense# <br /> 2 hone. -- � <br /> IS CERTIFICATE OF tJOf;KtiAJ'S COt9PENS'A1Ia�;. INSURANCE OBJ FILE t�JIfiH SJLHD? <br /> _ YES <br /> TYPEaOF WORK {:CFieck) ."4NEW-WEI1�` DE PS p "`RECONDITION '��„DE'S�fRi7CTI" <br /> WELL CHLORINATION ��`W .ABANDONMENT ® OTHER �� <br /> f . <br /> PUMP INSTALLATION [] PUMP-RtPAJR PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREgT: SEPTIC TANK 1 "� ' <br /> �R LINES P.I.T 4 VY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPGE�PI <br /> PROPERTY LINE �9PRIVATE DOME5TIC, TELL P` ---.OTHER <br /> tJBL<I.CnomESTIC WELL <br /> INTENDED'OSE TYPE OP-WELL <br /> Industrials Cable Tool CONSTRUCTION SPEC F-I,C.TIONS <br /> Domestic/private Dia. of Well Excavation r <br /> omestic%public --gilled. Dia. of Well Casing <br /> Irrigation Driven `. Gauge of Casing <br /> Gravel PackDepth of Grout Sea j <br /> Cathodic Protection Rotary <br /> Disposal Type Of Grout <br /> Geophysical Other Other Information j <br /> Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor <br /> -------------- <br /> PUMP REPLACEMENT: [j State Work Oon -� _-- -- <br /> e � • <br /> LUMP REPAIR• �' <br /> OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Approximate De _th <br /> _ Describe MateF-Idl and Procedure � <br /> I hereby certify that I have prepared this,applicat _on and that the work will idi <br /> with San2Joaquin county Ordinances, State Laws, and Rules and Regulations oflthe SaneJoin a <br /> aquinolocale <br /> Health Dist'r'ict. 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 insuch manner as to become subject to Workman's Compensation <br /> laws of California." J pi ation <br />[ WILL CAL FOR A GROUT INSPECTION PRIOR 70 AND A FINAL INSPECTION. i <br /> IGNED <br /> DR W PLOT PL N ONTREVERSE SIDE —`�"' DATE: /z:?-- //�7� <br />`HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DAVE ; <br /> PHASE iI GROUT INSPECTION r � <br /> VSPECTION BY D 7EPHASE III FINAL INSPECTION <br /> p INSPECTION '$Y <br /> DATE /S� <br /> 1 1426. . R . _• .. <br /> i1 <br />