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N <br /> �FFICE USE: _ 1601 E. Haz=elton Ave , Stock on, CA 95205 Perrriit No._2Z-,e _� <br /> TelY!Phone: (209) 466-6781 <br /> �'PPLICATitt 'r:jR tt�tCCNSTRUC'iI NOR PUMP PERMIT Date IsSued ., �.?J <br /> This Pormit -Expires 1 Year From Date issued <br /> w(Ccin�pleLe In Triplicate) <br /> Aj plication is hereby wade to the San Uuaqu•in Local Health District for a permit to construct <br /> and/or install the vrork herein describw#. This application is made in compliance with San <br /> jaaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. I I <br /> EXACT STREET ADDRESS 'Z U�� f 6C; D l CITY/TONIN <br /> ox <br /> rg ' <br /> Owner's 'lame i�CC�� .4P-K Phone <br /> F Address 0 G I�,' fE CityBCtl�7b } <br /> Contractor's dameG ALLYQUI 6 Licenser 76602 Phone Y62•S:i" <br /> I ' t•; rY." "' OM ' TON 111SURAMCE ON FILE WITH SJLHD? Y •S P--'— <br /> TYPECrR, I�'?GATE OF 0, P,:, S C�,�1'EEISr1T <br /> TYPE OF WORK (Check) : NEW WE-LLM-11" DILEP' N 0 RECOND TION (0 DESTRUCTION❑ <br /> 1 WILL CHLORINATION 0 WELL ARAN ONMENT ® OTHER <br />=1 <br /> PUMP INSTALLATION 0 PUMP REPA R C3 PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK -15b' SEWER LINES PIT PRIVY " ` <br /> 511,!AGE DISPJSAL •hI .LD b GEMS /SEEPAGE �f— OTHER <br /> Yet 'FE�L��CIESTIC WELL PUBL�f�UFEST IC W� I <br /> PROPERTY ;.INE -•. PRIVA� � <br /> INTENDED USE TYPE; OF WELL CONSTRUCTION SPECIFICATIONS I� <br /> Industria b o i >}i , of Well Excavat on 14 <br /> omestic/private Drilled Dia. of Well Casing � <br /> l r.� Domestic public _ I}river Ga ge of Casing <br /> 4 Irrigation Vel Pack Ge)th of Grout eaAA <br />'1 Cathodic Protection I�Rotary Tye of Grout <br /> 1 Disposal Other Ot er Inforniat on <br /> Geophysical Surface Seal Installed by: II <br /> PUMP INSTALLATION: ContractorL I PHE MU <br /> Type of Pump (44 UE9 8 CE H. a <br /> PUMP REPLACEME:dT: L-_I State Work Done Y <br /> <;r� ?UMP REPAIR: QState Work Done� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater a a dW race ure 4: <br /> r; I hereby certify that I have prepared this application ind that the work will be done in accordance, <br /> n` with San Joaquin County Ordinances, State Laws., and Rul s and Regulations of the San Joaquin Loca!� <br /> x Health District. Home owner or licensed agent's signat re certifies the following: <br /> t "I certify that in the performance of the work for w ich this permit is issued, I shall xx . <br />+' not employ any person in such manner as to become s bject to Workman's Compensation <br /> F I :ws of California." <br /> 11+IILL C F R A GROUT INSPEC ION PRIOR TO GROUTING AN) A FINAL INSPECTION. <br /> SIGNED _ TITLE: UW19K DATE:194 «19". <br /> (DRAWPE-OT PLAN ON REVS <br /> � • PHASE I R DEPARTMENTUSE NLY <br /> r <br /> APPLICATION ACCEPTED By _ DATE <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'y iF3SPECTION BY f GATE a0 � IN PECTION BY DATE 11-z2�c <br /> EH 1426 Rev. 12-77 7 /78 <br /> h s <br /> � °t <br /> air }` ,: W r d #{ t t r✓x �� r�$` a c^1 _ eiz %a¢ <br />