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JAN JUAQU1N LUGAL MtALIM U1�,IKILI <br /> FFICE USE: 1601 Hazelton Ave. , Stockton, CA ' 105 Permit No. -7,f_10 <br /> Telephone: (209) 466-6781 Y` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From Date Issued PV CApplication is hereby made to the San Joaquin Local Health District forperm1 stMuct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDR SSC6 :5 Q A/' 9/40'-_ VlLr� /?DC <br /> ITY/TOW A7a0 -�( <br /> Owner's Nam <br /> L J__ gQ " Phone'759 - 3 `f e Z <br /> Address I CityO emEhlr <br /> Contractor's Name _ �icense?1/ 7702 Phone 8 / 7 - Z/771- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L-I/DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ p <br /> DISTANCE TO NEAREST: SEPTIC TANKf3Q, SEWER LINEVS0 ' PIT PRIVYA//-�- <br /> SEWAGE DISPOSAL FIEL SSU ' CESSPOOL/SEEPAGE PIT /7- OTHER ) C <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation , 5 <br /> c/6omestic/private e --'Bri11ed Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation gavel Pack Depth of Grout Sea <br /> Cathodic Protection Mary Type of Grout C1, 5/n IZA <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump —H-P <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: ❑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 accordanc <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 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 /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: �7- ���� <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLYPHASE I n�O / <br /> APPLICATION ACCEPTED BY ddlwall 4� DATE 2 -7k <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> [NSPECTION BY DATE_:F -Z r- 2Z INSPECTION BY �r�(/��_ DATE q- 74 75( <br /> H lag rRcv 19_77 <br /> 117Q 9M <br />