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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No. 79— Z <br /> FOB FFICE USE: 1601 E. Te�ephoneAve�Z09}°466�6781A 95205 <br /> APPLICATION FOR WE . 'dOh+��TRUCTION OR PUMP PERMIT <br /> Date Issued ?--13-7 <br /> This . Permit Ex ires 1 Year From Date issued <br /> Complete In Triplicate <br /> Applicat7o <br /> n is herebY 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 <br /> with an <br /> Joaquin County Ordinance No. 1862 and the- Rules and Regulations of the •San Joaquin Local Health <br /> District. � { <br /> CITY/TOWN <br /> EXACT. STREET ADDRESS $ --- � <br /> Phone .3 <br /> Owner' s Name <br /> City_ d&&L <br /> Address - " <br /> License#3 <br /> Contractor' s Name <br /> Phone <br /> 'S CERTIFICATE—OF'ti�tORKfiAt�'S CJi1PE�ISATI-011 I"ISURAINCE ON' FILE <br /> IIIT}1 SJI_HD? YES NO <br /> -TYPE OF WORK (Check) : NEW WELL& DEEPEN C RECONDITION ❑ DESTRUCTION❑ <br /> — WELL CHLORINATION D WELL ABANDONMENT 0 OTHER.() <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK20 FIELDER LINECESSP04L/SEEPAGEPRIVY <br /> PIT 1f�' OTHER <br /> --SEWAGE_DISPOSAL TIC WELL PUBLIC DOMESTIC. WELL ' <br /> PROPERTY LINE PRIVATE DOMES ._ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> _ Drilled Dia. of WellCasing " <br /> Domestic/public x Driven Gauge of Casing__ <br /> Irrigation Gravel Pack Depth of Grout Sea r <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Installed b : <br /> PUMP INSTAELATION: Contractor H.P. <br /> Type of Pump r- <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: . ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter •.. ' 11 Ap imate Depth <br /> Describe Mato a and Procedure <br /> I hereby certify that I have prepared this application an that the work wil be done in accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> I 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 /> r laws of California. " <br /> E I WILL CAL( FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: C`��137 <br /> D W P L N ON REVERSE SIDE <br /> " FOR DE ARTMENT USE ONLY 4 <br /> PHASE i DATE <br /> APPLICATION ACCEPTED BY -p <br /> ' ADDITIONAL COMMENTS: _ <br /> -A•PHASE II GROUT INSPECTION � PHASE III FINAL INSPECyi�� <br /> INSPECTION BY �• DATEINSPECTION BY DATE &12 ?C? , <br /> t 7$ 2M <br />