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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601. E. Hazelton Ave. , Stockton, CA 95205 Permit No. -7f-- 311T <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued --3v-? <br /> This Permit Ex ires 1 Year From' Date Issued <br /> Complete In Triplicate <br /> Application is heeby made to the San Joaquin Local Health 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 Rules and Regulations``of.the San oaquin Local. Health <br /> District. (E/oFrontage <br /> Mokelumne Aqueduct Right of Way 70EXACT STREET ADDRESS Road East Hwy 99 /TOWN Stockton <br /> 00 <br /> Owner's Name East Bay Municipal Utilit District Phone 415 835-3000 <br /> Address .2130 Adeline Street . City Oakland 94623 <br /> Contractor' s Name License#Pa* �- Pho ' `- F7" <br /> IS CERTIFICATE OF WORKt�At�'5I0'iP NSATIO" URA?1C'E�I"CE � �MLHD? YES NO <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN CI RECONDITION �, DESTRUCTIO.N_[j <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHERM '. ra+�hod.ic <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ PUMP REPLACEMENT C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Unknown 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 1011 <br /> Domestic/private Drilled Dia. of Well Casing None <br /> Domestic/public Driven Gauge of Casing None <br /> Irrigation Gravel Pack Depth of Grout Seal 245 ' <br /> - x—Cathodic Protection Rotary Type of Grout Concrete <br /> Disposal Other Other Information See attached dw 6941G <br />'r Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br />' PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate- Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done 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 licensed agent' s signature certifies the following : <br /> "I certify tha in the performance of the work for which this permit is issued, I shall <br /> Wt employ Jypersonsin such manner as to become subject to Workman's Compensation <br /> r, <br /> laws of California. " <br /> I WILL CALL AOR A .GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION" <br /> SIGNED TITLE:Assoc.Corrosion--=Eli rDATE: 1-24-79 <br /> q:����DRWPLTL N ON REVERSE SIDE) ee°wdttached dw 6 4 <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> P ASEI GROUT INSPECTION PH E III INAL INSPECTION 1 i' <br /> INSPECTION BY DATE 1��- 15• INSPECTION BY - 11DATE <br /> * Unknown at time of application. Wto bey .�7.R. 2M <br />