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JAN JUAQUINS•LUUAL`jHtAL111 U1J1K1U1
<br /> FOR FFICE USE: • 1601 E. Hazel;ton,'Ave'.-, ,Stockton, CA 95205 Permit No.
<br /> Tel:eph'oni.e3(249) `1466,-r-6781 Date Issued 2,z
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<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT
<br /> This ;Permi;t` Ex f res '1'._ Year' Fro+n Date"Issued` ,
<br /> Complete In Trip icae
<br /> Appl i cati on is hereby made to the San .Joaquin ,Local:- Health ,Di s t r J c for;a permit jo,,canstruct
<br /> y and/ort•i^nstial I otheemork :he:rein .des.cr.i:bed ,%,,This application-,is.,made, in:,compliance with, San
<br /> oaquin zCo`unt ' _Ordi'nance..No:.. 1862 and ;the ,Rul,es.and;•Regulations, of, the, San Joaquins -Loca1 Health
<br /> T)istrict.
<br /> ,, s a ' • CITY/TOWN cl
<br /> EXACT'(STREET,`'ADDRESS 7 D 7 O . .._
<br /> t r:-.Y
<br /> ;. Phone
<br /> Owner' s Name
<br /> ,,,Address ,G►.�,.. /� L`7cens
<br /> Contractor's Name Phone
<br /> TS CERTI.F'ICATE OF 14ORKtIAN'S �COl3PENSATIO'! I"1SUfi ikirr .ON FILE WITH SJLHD? YES t—r' NO
<br /> TYPE OF WORK (Check) :. _,NEW, WELLE---DEEPENw0_ RECONDITION ❑ DESTRUCTION❑
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<br /> WELL- CH'LORINATION Q WELL ABANDONMENT a OTHER .. �
<br /> PUMP INTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C! '
<br /> DISTANCE TO-NEAREST-:1 - SEWAGE DISPOSAL FIEL-DER�LINECESSFO.L/.SL PAGE.,P '
<br /> ,';_ EEPAGE...PI __,�,_.. . OTHER
<br /> --' �"P.R_ OPERTY'LINE - `PRIVATE DOMESTIC rWELL ' PUBLIC DOMESTIC WELL
<br /> INTENDED 'USE �;"� TYPE OF WELL CONSTRUCTION SPECIFICATIONS
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<br /> Industrial Cabl,eTool Y Dia. of;�Wel l Excavation i
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<br /> ..--"Domestic/private Dri 11 ed -'.Dia. of..,Wel 1 Casing J,
<br /> Domestic/public Driven '..:- Gauge of.- Casing
<br /> Irrigation Gravel Pack � Depth ,6f Grout Sea
<br /> f Cathodic Protection Rotary Type .of Grout
<br /> ,Disposal Other `fes Other tI.nformattion
<br /> Geophysical Surface�Seal Installed b
<br /> PUMP INSTALLATION: Contractor .
<br /> Type of,Pump H.P.
<br /> LPUMP REPLACEMENT: ❑State Work Done :'
<br /> PUMP REPAIR:i ❑State 'Work .Done.
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<br /> DESTRUCTION OF WELL: Well Diameter: Approximate Depth
<br /> . . � ,�:
<br /> 7 - ;---pescribe=Materia ''and-Procedure'°
<br /> I hereby certify that I have prepared this application and that the work will be done in accordar
<br /> with San Jo6qui n •County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loci
<br /> k 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
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<br /> j '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.T_Q GROUTING AND A FINAL INSPECTION.
<br /> t SIGNED TITLE: DATE:4L Z
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<br /> z DR W I LOF PLAN UN REVERSE SIDE
<br /> y FOR. DEPARTMENT USE'•ONL'Y
<br /> PHASE I DATE__
<br /> ADDITIONAL
<br /> I z
<br /> APPLICATION ACCEPTED BY
<br /> ADDITIONAL COMMENTS: y "
<br /> PHASE II GROUT INSPECTION;.,, PHASE III FINAL INSPECTION
<br /> INSPECTION"BY`` DATE : INSPECTION SY DAT
<br /> f ru 1 nec oma., 19--77-- ' $ T
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