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_ JAIL JUHQl11fV;.LMAL hHtALlhi ul�IrclLi Permit No-- - 10 3 _ <br /> FFIGE USE: isa E. Hazelton':6e:. ; ;ttockton, CA 95205 <br /> C � Tel-ephone�— :(209) '4,06-6781' Date Issued -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This :Permit. Ex ,i res 1..Year, From Date':-�Issued ,. <br /> Complete In Triplicate <br /> •.._1 - <br /> Application is hereby made to the San Joaqujn Local.;Health Districtzfor,.a permit to;;construct <br /> and/or install:.=therwork herein :descr. bed _- iThis� a:pp.1.ication -is,mage:;;in"compl,lance with�Sa <br /> Joaquin Gounty�;Ord.i:na;nce <Na..- 1862.-and th,e :RuIes ;and ;Regula.tio s, of. the San..�loa.qu�n Loca! 'Health <br /> f�istrict. <br /> CITY/TOWN <br /> STREE :' DRESS �� -� <br /> EXACT`` T AD <br /> Phone <br /> Owner's Name <br /> Address .. . ..,. <br /> n <br /> Cl71 <br /> Li tens <br /> TS CERTIFICATE OF. WORKMAN'S CJFSPENSATIO"I 'I143SURA' E 'N <br /> dCE ON FILWITH SJLHD? YES 0 � <br /> TYPE`OF WORK (Check) : NEW WELL[Rl"�DEEPEN ❑ RECONDITION Q DESTRUCTIONS <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION M---PUMP REPAIRO PUMP REPLACEMENT E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK fd SEWER LINES PIT PRIVY <br /> SEWAGE DISFrOSAL :FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I� CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation - V <br /> - Drilled Dia. of Well Casing r } <br /> — Domestic/private - <br /> Domesti'c/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea D <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Instal ed b - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: i ,Q state Work Done <br /> PUMPREPAIR ' QState Work Done <br /> DES7RUCTION OF WELLti We1l,Diameter Approximate Depth <br /> - Desc-r.,i be Materi a and Proce ure <br /> w <br /> t I her`eby,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 /> i 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 f <br /> not employ any person in such manner as to become subject to Workman's Compensation f <br /> 1;Yd <br /> laws of California." <br /> I 'WILL °CALL A" GROUT- INSPECTION PRIOR TO UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �. <br /> (DRAW T L N ON REVERSESIDE <br /> DEP RTMENT USE ONLY <br /> -/ - <br /> _PHASE— DATE {O - ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III' FINAL INSPECTION <br /> INSPECTION .BYE DATE <br /> _ INSPECTION BY' DATE r . <br /> M1°178 <br />