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r SAN JUAQUIN LULAL HLAL I N UI5 I KiC l <br /> OFFICE USE: 1601 E. Hazelton Ave. , �Ste-kton, CA 95205 Permit No. 77 ?3 1 <br /> Sof :uo IA- Telephone: (209), 466-6781 <br /> a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 31 L <br /> 1.79 <br /> This Permit .Ex ires - 1 Year From Date Issued <br /> k , Complete In Triplicate <br /> Application is hereby made toythe San Joaquin Local Heal-th District for a permit to construct <br /> anal/or install the work herein described. This application is made in compliance with. San <br /> , oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Loca1' Health*.,; <br /> District. II <br /> { G <br /> EXACT STREET ADDRESS In ej " CITY/TOWN <br /> Owner's Name Phone <br /> Address rn C <br /> Ci ty - r <br /> Contractor' s Name License# Phone X22 .I- <br /> :S CERTIFICATE ;OF'14ORMM S-C'01PENSAT IO,1 Ins-0 RA rct ON FILE WITFI SJLHD?" YES <br /> TYPE OF WORK (Check) : NEW WELLJO DEEPEN ❑ RECONDITIONS© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION RL PUMP REPAIR❑ PUMP REPLACEMENT 0 d <br /> DI5TANCE TO NEAREST: SEPTIC iTANK *,b,.e_ SEWER LINES ro,e PIT. PRIVY <br /> SEWAGE DISPOSAL F-I-E-L-D---EESSP00L/SEEPAG-E"'PfiT. ---BOTHER <br /> r PROPERTYiLINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> 1NTENDED'USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation A <br /> Domesti0private Drilled Dia. of Well CasingDomestic`/publicDriven Gauge4of Casing f Irrigation Gravel Pack Depthof -Grout SealCathodic Protection i ; Rotary .Type of Grou't�-q�s San�[ <br /> Disposal Other Other I 1nformati on i r <br /> Geophysical -�.., Surface'S.eal Installed by: __-0,;.,�.S <br /> I — - ._ _ <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump -= A A ir-' H.P. I Z,.Z <br /> PUMP REPLACEMENT: [] StateWork Done <br /> PUMP REPAIR: y ❑State Work Done <br /> DESTRUCTION -OF ',WELL: Well Diameter Approximate Depth . y <br /> ` ,, Describe°Materia and Procedure <br /> I hereby certify that- I. have or <br /> prepared this application and that-qhe wk�w111 be Cane- in accordant( <br /> with ,San Joaquin County. Ordinances , State Laws , and Rules and Regulations of the San Joaquin-Local. <br /> Health District. Home owner,or;rlicensed agent' s signature certifies the following: x <br /> "I certify that�in the performance of the work for which this permit is issued, I shall -4 <br /> not employ any person in' such'manner -as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL FQR A GROUT INSPECTION PRI,OR .TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED /716z '�._ TITLE: DATE: I7 <br /> DRAW PL T PL N ON REVERSE SIDE <br /> f?OR DEPARTMENT-USE ONLY <br /> PHASE I - - ti <br /> APPLICATION ACCEPTED B ! *DATE <br /> ADDITIONAL COMMENTS: -" I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �. r3_ DATE 4z- �- 7 <br /> _ � INSPECTION BY-�=ef DATE <br /> EH 1:4215 Rev- 12-77 ' 1 /7A 9M '` <br />