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fi JHIX UUAQUIN LULHL htAL I h U13 I KIL I <br /> FQR FFICE USE: 1601 E. Hazelton Ave: Stockton, CA 95205 Permit No. 25-//6ff <br /> Telephone: (209)' 466-6781 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7_ -J I <br /> This Permit Expires I Year From Date Issued <br /> (C mplete 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 the Rules and Regulations of the San. Joaquin Local Health <br /> District. r <br /> EXACT STREET ADDRESSg7,,3 5, tSCAko�,/ — &44o J Zj, CITY/TOW" AA _ -? <br /> Owner's Name SEL p4ss1 DA - - — Phone c9 <br /> Address S4 k7 L5 City L-Scig4x +) <br /> Contractor' s Name f, D Li cense#,.22%/ Phone J� <br /> IS CERTTrICATE OF. WORKAIAN'S COIiPENSATION INSURANCE ON FILE WITH SJLHD? YES Y NO <br /> TIYPE OF WORK (Check) : NEW WELTLM �DEEPEN p RECONDITIQN QDESTRUCTTON[ -�� -WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C] PUMP REPAIRid PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .-PRORERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Seal <br /> Cathodic Protection Rotary , `Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j]State Work Done <br /> PUMP REPAIR: T State Work Done %DQ P-4-24 <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 accordancE <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locall <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 FO A GROUT T PECTION PRIOR TO GROUTING ANDA IN L INSPECTION. <br /> SIGNED TITLE: DATE:_- .�yo,2�/�1� <br /> a.. ,, DRAW PLOT PLTN ON REVERS SIDE), <br /> ?y FOR DEPARTMENT USE ONLY <br /> PHASE I �{ <br /> APPLICATION ACCEPTED BY DATE 2F 7,f <br /> ADDITIONAL COMMENTS -, <br /> PHASE PHASE III FINAL INSPECTION <br /> INSPECTION BY }.,`.'` '', . .`,�` TDATE INSPECTION BY DATE <br /> CEJ 1 AI-- n_.. 7 n -7'f - "" � 1-76 7Ad <br />