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JUHQU.iN LUUH�. htw�.IM uiJIKIUI Permit No. ;Z�j <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FORWELL ­CONSTRRuCTTON OR PUMP PERMIT <br /> This 'Permit ,EX fres 1 Year From Date Issued <br /> Complete In Tri-plicate <br /> Application is hereby made to the San Joaquin Local. Heal h District foinr -a permit compliance with construct <br /> and/or install the work herein .descri.bed. Jhis _appl:icat <br /> ionis made� <br /> oan .;n County .C?rdinance rtiU. 1862 and the Rules and Regulations, of the San Joaquin Local Health <br /> ni5tr'Ct. f <br /> EXACT STREET,A 5 PC.!/� CITY/TOW L�„�-�� <br /> Phon <br /> Owner' s Name <br /> c � -' <br /> City <br /> Address 1Gp <br /> Contrattor's Na e r <br /> L i c e n s �on-x'40 hone 'Z-E <br /> IS CERTIFICATE OF WORKMAN S COMPENSATIOM INSURA1,10E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ SELL ABANDONMENT ❑ OTHER 0 <br /> E PUMP INSTALLATION q�� PUMP REPAIR❑ PUMP REPLACEMENT E3 <br />, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT ` OTHER______^ <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL -- PUBLiC DOMESTIC WELL <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �Ia ustrial Cable Tool Dia. of Well Excavation <br /> �Do�mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven � w Gauge of Casing <br /> Irrigation Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> M Disposal Other Other Information <br /> Geophysical Surfac Seal Installed b <br /> PUMP INSTALLATION: Contract. r 'i C <br /> Type of ump H. <br /> PUMP REPLACEMENT: Q 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 emp1 any person in: such manner as to become subject to Workman's Compensation <br /> laws o California." <br /> I WILL CA F R A GRO T INSPECTI RIOR 0 GROUTING AND NAL INSPECTION. <br /> SIGNEQ—XTTITLE: DATE: �C <br /> t <br /> DRAW PLOT PL N ON REV S E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> ' APPLICATION ACCEPTED BY <br /> 'ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE 1TI TNAL INSPECTION <br /> iINSPECTION BY DATE INSPECTION BY <br /> DATEF" <br /> 1/78 2M <br />