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S <br /> SAN JUAQU1.N ,LUGAL HLAL I H W S I KIS I <br /> FFICE USE: 1601 E. Hazelton Ave': , . Stockton, CA 95205 Permit No. <br /> Telephone. (209), 466-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT nate Issued <br /> This Permit Expires 1'Year From Date Issued <br /> ^8 Complete 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of-the San Joaquin -Local Health <br /> District.. .27-,S"Z "dBa-9A-4 4 <br /> EXACT .STREET ADDRESS i' IpAt z Rd :CITY/TOWN <br /> Owner's Name w a< T ,� u r ; , Phone <br /> Address C9f3 71-0 City ' � � �c7�•� <br /> Contractor's Namen ._,(,� �'AA. License# 26f 7G 1 Phone �Z eoy <br /> I'S CERTIFTCATE OF WORKMAN'S COMPENSATIO"J INSURAIIJCEf_ON FILE WITH SJLHD? YES Z_ NO <br /> N � <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION L WEL0ABANDONMENT p OTHER 0 i <br /> PUMP INSTALLATION PUMP/.,REPAIR 0 PUMP REPLACEMENT E] S i <br /> A <br /> G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ?. <br /> SEWAGE DISPOSAL FIELD -- , CESSPOOL/SEEPAGE PIT ' OTHER O <br /> PROPERTY LINEe-, PRIVATE DOMESTIC WELL ---- PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OFFWELL ,` CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable fool Dia. of Well Excavation --. : <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven' - Gauge of Casing_ r� <br /> Irrigation Gravel Rack \'-Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other, Other Information <br /> Geophysical '4 Surface..Seal Installed by: <br /> PUMP INSTALLATION: Contractor Vv,,.*V'e A 'a «. . ,�� <br /> Type of Pumps' 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 r <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 Local <br /> Health District. Home ow -Tice'nsed agent's signature certifies the following: <br /> "I certify that in the--performance 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 FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED_4_/ <br /> TITLE• DATE J ''- t <br /> DR W PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -� <br /> APPLICATION ACCE BY , t DATE .2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 11;_,]FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY M2 DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />