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5AN JUAQU1N_LURAL HLALIH U1J1K1U1 <br /> FOR OFFICE USE: .E. Hazelton Ave. , Stockton, CA 95205 Permit No.7�_/ �3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,-;j-.2f.- <br /> This <br /> ,-/-2This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anal/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. <br /> EXACT STREET ADDRESS J V, M AZ,,A CITY/TOWN ,''SC <br /> Owner's Name &6 Phone-O— -- ,,�29y,2' <br /> L[� <br /> Address .,S A rl-) L Ci ty f-:.S't��J <br /> Contractor' s Name , Z2� -'moi o -4 , u•i.J License#,-771/,0ic Phone 61519-12241)_7 <br /> TS CERTIFICATE OF WORKMAN'S C0111PENSATIO'1 INSURANCE ON FILE WITH SJLHD?_ YES NO <br /> TYPE OF WORK (Check): NEW WELL 0- DEEPEN [] -RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT EJ OTHER❑ <br /> PUMP INSTALLATION 4N PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> �v <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <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 5QR A GROU INS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ,.tet , DATE: —,25 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �Lj Z�� <br /> DATE ai 7e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY4k DATE' ZJ; Y <br /> EH 142 78 2M <br />