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SAN JUHt�UiN LU(:HL HEHL I H U1S I k1C l <br /> EFFE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued3- 3 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete InTriplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct f <br /> and/or install the work herein described. This application is made 'in compliance with San <br /> 2oaquin County - <br /> mcr <br /> Ordinance No. 1862 and the Rules —to <br /> EXACT <br /> of the San Joaquin Local Health <br /> District. a, \c-r`& w <br /> EXACT STREET ADDRESS , - ,� Q� �� CITY/TOWN <br /> Owner's Name ALF- &oe7`J jz,) - a -ag d d6LII Phone IF-35- <br /> Address <br /> " 5-Address C° �r�na�r� f)' - City <br /> Contractor's Name License#,?90,F/,3 Phone 1:1y15_9_ , <br /> I5 CERTIFICATE OF WORKHAN'S COMPENS-ATIO"l NSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check): NEW WELL Z DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Ea 'p <br /> DISTANCE TO NEAREST: SEPTIC TANK /a0 SEWER LINO-' PIT PRIVY C� <br /> SEWAGE DISPOSAL FIELD '1E OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE "PRIVAT�S1iIJ: L PUBLIC DOMESTIC WELL <br /> r- <br /> INTENDED USE TYP OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 <br /> .able Tool of Well Excavation ' <br /> Domestic/private Dri11e�, ia. of Well Casing ' t1- <br /> WELL <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel1Pkc�C_ Depth of Grout Sear i <br /> Cathodic Protection ; Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical —� Surface Seal Installed <br /> UMP INSTALLATION: Contractor A <br /> Type of Pump H. <br />`4UMP REPLACEMENT: ❑StateWork Don <br /> UMP REPAIR: OState Work Do e <br /> Az <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> ealth 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 /> -WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE:_ _ DATE: :,P a_72 <br /> DRAW PLOY PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 67W <br /> ADDITIONAL COMMENTS: <br /> P I GRO T IN E�TION PHAS III FINAL NSPECTION <br /> INSPECTION BY A—TES-% _:Z, <br /> INSPECTION B DATE,- <br /> -- <br /> EH 1426 Rev. 12-7778 2M <br />