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NOU-11-1599 13 07 MDDRMRN'S WATER P 02 <br /> CE USE: , 1601 E. Haiengoite—s- <br /> Av�y�5tockton, 'CA 95205 Permit No. <br /> ` <br /> Tele •Z kA6-678. .-"� Date Issued&APPLICATION F =R, CO N'S-TRLItI:ION #t= PUMP' PERMITd'!-r,.l A ' �•ZR V 3� � 3 YJ 1'1 ,L`Tear FromMate 7�ssued '�;:tc,c• Y ,imp ete , n Triplicate) <br /> sate r �� _ r <br /> _.a',I <br />)plica,'tion is hereby made tot the San 'Jo quX nLDcal HepAth -Distract. fpr--a pe,rmiti.to:-construct <br />�d�r3rc sta �3heT �1rkyh&+e4n1descri Ied evThisja.pP-1_1 ationj i,vomade_ if*r, ce pliaace"withv Sa-n• <br />�aQuir�° o°ung+=0rd� nc N , 1862--aad t $R�fil�s� drRegu�aticns►,af theu,5arvrJ,9agoJ ?LoW, Health <br /> pct, •- .. _ "�, <br /> FR 0alt3;1-;str <br /> oe <br /> nr,�,�. -�� <br /> t +F ry <br /> L� LLY�.�i>u� t.. int.✓ �1 .�7" N ` J <br />`AG7 sa'REET A-DRE ' <br /> iner'sl dame K 7 Phone <br /> 2 l <br /> ty <br />)ntractor's dame �^r 1� License# <br /> Phone �- <br /> 5 CERTIFICATE OF WORIglAIP S COIMTENSATIOfIia <br /> � SU `ICE ON FILE WITH SJLHD? YES NO <br />(PE OF WORK (Check) : NEW WEEL t2r"_ DEE ON O RECONDITION Q DESTRUCTION[� <br /> WELL CHLORINATION Q' W ABANDONMENT 0 OTHER <br /> ❑ <br /> PUMP INSTALLATIOX�� � REPAIR(J PUMP REPLACE <br /> ISTANCE TO NEAREST` SE ?TIC'TAI+IK = WEa L.1�lES IT PRIVY, <br /> '", -.._ _ - SE. (AIxEx•QISP S =� CLQ ' " r` C L/SEEPAGE T1r'aftTHERPROPERTY LIN IVAYE WESTIC WELL-- PUBLIESTIO WELL <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial el. oo Dia. of We Excavat on / 1H <br /> mestic/private - � )I Dla. of Well Casing `1 L • <br /> D-ames-cic/pubI i c - `= Dr VA'. Gauge or Casing s <br /> De tl�. of Grout SES <br /> �r p <br />�'Cathod3cox # ctior ;� Ron r Type of Grout - - <br /> ,Disposal i ��L '=- "r' • Otte - Other Infor�mat on surface Seal Insta e <br />—Geophysical •" ' � <br /> UMP INSTALLATION, — 'Corrt'ractor f r t,l ,� <br /> f Tyke of Pump H.F. <br /> UMP REPLACEMENT: t [�,Sta eJWork Von6 ' <br /> UNDP REPAIR: ❑State - Work 00 T <br /> I <br /> ESTRUGTION OF{ WELL: i �[e'I`1 Diameter I <br /> Approximate Depth <br /> scribe Maters a�nd Procedure <br /> � f1 I rl <br /> herebycertifythat I h ve prepared; th,#s applicatzo' an4 that the work will be done in accordar <br /> ith Sai Joa�iCounty Ordinances , 5tataws;-and Rules and Regulations of the San Joaquin LocE <br /> ealth District.. - Home owner or licensed]~agent' srsignlature-certifies the' following . <br /> I certify that in"'-the performance; p , the work for,`which this permit is issued , I shat l <br /> not employ' any persone` ,in such man$er� a"s to becomsubject to Workman s Compensation: <br /> laws of Wiforpla." a,' I� ij. , ', <br /> WILL CALL FOR A IN_RfCTION PRIM �o-•GROUTING ,AND A FI AL I SPEC ION. Z <br /> .�� r. , u. DATE: 1l <br /> "Lq <br /> IG�]ED ' - .•-r ,— _ A /��T'L : - <br /> i <br /> y' J= �, ,.` DATE <br /> 1=IOK ACCEPTEi 331�`�' s' _ <br /> DOI71ONAL CO*ENTS PHASE III FINAL INSPECTION <br /> PHASE 'It. GR 1I i-TSPECT4O - i <br /> NSPECTION BY - DATE INSPECTION BY DATE <br /> 7 r � o 7u <br />