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r ',AN JUAIlU1N LUCAL HtALIM UlJ,Mit ' <br /> ED FICE USE: !� 1601 Hazelton Ave. , Stockton, CA ,.,�205 Permit No.>9_6 0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -/ -7 <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application 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 with -San <br /> ,'oaquin County Ordinance No. 1862 and he Rules and Regulations of the San Joaquin Local Health <br /> District. r/ <br /> EXACT STREET ADDRESS�Og Wen- ,)F 7E/4/EuL ��� CITY/TOWN 4zA4rv' <br /> Owner's Name- ::!Zhu Iz Q N D-Ppf, AL Phone <br /> Address Aa y�ms s e, 7.� � City rsc a, ate✓ <br /> Contractor's Name /i�,, , � i ��v LicenseSa;90ia Phone <br /> S CERTiFiCATC OF WORKMAN'S CO'1PENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ o%D weti 70 &4,eWELL CHLORINATION O WELL ABANDONMENT 0 OTHERjffi SeK�.c� <br /> PUMP INSTALLATION f4 PUMP REPAIR❑ PUMP REPLACEMENT 0 6`/ pw A fff_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES`SP OL/SEEPAGE PIT OTHER c9 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL L1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatio- n <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor rl� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []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 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 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 R A GROUT PE TION PRIOR TO GROUTING AND A F NAL NSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PL PL N ON REVERE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> TP—PLICATION ACCEPTED BY M „ DATE / 7 /7 91 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE NA- INSPECTION BW/ DATE/ Y <br /> EH 1426 Rev. 12-77 1 1m7Q _NM <br />