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SAN JUAQU1N LUCAL .HLALIH llfJIKi[ll <br /> FFICE USE: Vol 1601 E. Haze Ilk. <br /> , <br /> Hazelton Ave. , Stockton,",CA 95205 Permit No. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP, PERMIT Date Issued »' <br /> ' Y ..!.. <br /> This Permit Ex .ire's. I.-Year.From Date Issued <br /> Complete In Triplicate <br /> lApplication is hereby made to the San Joaquin Local .H <br /> and/or install the work herein described. This application District made fnrcomplimit to construct <br /> Distri n County Ordihance. 1Jo. I862 and the R s and Regu.1dt' ns of the SanpJaanuenwLoh San <br /> District q cal health <br /> EXACT STREET DDR S'Sp�p��/ ���� <br /> Owner's Name CITY IT <br /> r , I <br /> Address, Phon <br /> Contractor's ame City = <br /> Lice <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I"dSURANt Q D mane <br /> N FILE WITI! SJLHD? YES t� ti0 <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION <br /> -� <br /> WELL CHLORINATION 0 WELL ABANDONMEN)o OTHER r� (� <br /> PUMP INSTALLATION ❑ PUMP REPAIR C] PUMP REPLACEMENT, [ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> r SEWAGE. DISPOSA FL FL IELD. `CES OPS OL/SEEPAGE PIT <br /> PROPERTY LINE -. PRIVATE THEDOMESTIC WELL- PUBLIC DOMESTICRWELL <br /> TYP - <br /> INTENDED USE E)OF• WELL <br /> ndustrial CONSTRUCTION SPECIF T NS <br /> Domestic/private Cable Tool 4 Dia, of Well Excavation <br /> Domestic%public Drilled Dia. of Well Casing <br />-,______`Irrigation ;�Dri ven Gauge of Casing <br /> Cathodic Protection --e� G ravel Pack Depth of Grout i <br /> Disposal Rotary Type of Grout <br /> Geophysical Other Other Information <br /> Surface S I Istat e b <br /> UMP INSTALLATION: Contractor <br /> Type -of Pump f <br /> LMP REPLACEMENT: H.P. <br /> tate Work.7b0 <br /> n <br /> LMP REPAIR: <br /> 0S.-tate Work Done s <br />:STRUCTION Or WELL Well Diameter <br /> Describe,Materia andfProcedure "Approximate Depth <br /> hereby certify that I have prepared this application and that the-work wil-T be de <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San JoaquinoLocal eI <br /> alth District. Horne 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 /> DILL CALL FOR A GROUT INSPECTIONZ-1.PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 3NED TITLE: <br /> DATE: <br /> DR W.: PLOT PL N ON REVERSE SIDE <br /> k5E i �. ate„ .. ,i` FOR DEPARTMENT USE ONLY <br />'LICATION ACCEPTED BY ; . ' <J <br /> fITIONAL COMMENTS: ,7, , DATE 7� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION f <br /> PECTION BY DATE � <br /> �. � INSPECTION BY DATE_5:Q/-2,r' <br /> 1426 Rev., 12-77 may`, <br />