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g0 SAN JOAQUIN" LOCAL "HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton "Ave. , Stockton, CA 95205 Permit No. <br /> i ( Telephone: (209) '466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9 Zs._Z9- <br /> ljhis •Permit Expires 1 Year, From Date Issued <br /> 1 Complete In Triplicate 7 - . . ' - I ;' <br /> Application is hereby made t�� the.- San Joa" uin Local Health 'Dis ri <br /> q t ct for a permit to construct <br /> and/or 'install the work, herein described.. This application is made in compliance wi.th. ,San <br /> doaqu i n`County Ordinance No:j 1862.,and the Rules and Reg uleti ons of .the.Sa.n. Joaqui n Local: Health <br /> District. , . <br /> EXACT STREET ADDRESS CITY/TOWN �I��-• a <br />[ <br /> Owner's Name UPr BAJA Sl re Pr Phone f�Z3-Z3"II <br /> G Address" f? Vo 1�k, <br /> Ci.tY_ In <br /> ContraName <br /> -c - <br /> ctor s Name -License# Phone <br /> IS CERTIFICATE OF'WORKt1AN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE QF WORK (Check) : 5 NEW WELL CI DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT OTHER 0 <br /> PUMP INSTALLATION p PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC; TANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabl-e- Tool- - -N" Dia":" of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r - Driven Gauge of Casing <br /> Irrigation .Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal -Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump - H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Done j <br /> PUMP REPAIR: ❑State Work Done J <br />-DESTRUCTION OF "WELL: Well Diameter <br /> Describe Materia and Procedure l <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 , St Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home wner or li agent' s signature certifies the following: <br /> "I certify that i e rfo of the work for which this permit is issued, I shall <br /> not employ an a so in s nner as to become subject to Workman 's Compensation <br /> 1 aws, of Ca a I <br /> I WILL CALL GRO INS ON PR OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED,, TITLE: ' DATE: <br /> (DRAW PLOT PC N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION CEPTED BY DATE <br /> ADDITIONAL COMMENTS : i —–� <br /> PHASE II GROUT INSPECTION PHAS III F NAL INSPECTION k <br /> INSPECTION BY DATE INSPECTION BY DATE_7— Q_ <br /> EH 1426 RPV 12_7i " , <br />