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4 <br /> r /1661 <br /> I SAN JUAQU1N LUGAL HEALIH 11151K1UICE USE: E. Hazelton Ave. , Stockton, CA 95205 Permit No.z�1_4/1 O <br /> Telephone: . (209) 466-6781 4 V. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/7/Z_;;' <br /> This Permit Ex ices 1. Year From Date Issued <br /> Complete In Triplicate <br /> AQplication is hereby made tolthe San Joaquin Local Health District forea permit to construct <br /> dod/or install the work herein described. This application is made in compliance with -San - <br /> oaquin County Ordinance No. 1862 and he Rules and Regulations .of .the San Joaquin- Local Health <br /> D4strict. - �� ly• / 2� <br /> EXACT STREET ADDRESS . _ e CITY/TOWN <br /> Owner's Name i Phone �� <br /> Address .. - - ,v r City LS�x�L�Id <br /> Contractor' s Name /� „i License#��0 d Phone <br /> 7S CERTTFTCATE OF WORKMAN'S C0111PENSATION-VISURANCE ON FILE WITH SJLHD? YES XNO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ® DESTRUCTION❑ o.ct3W&Aw- 70 b�e <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHERP§ <br /> �e+z�`�c� <br /> '`• PUMP INSTALLATION f4 PUMP REPAIR PUMP REPLACEMENT by pwwe�.• <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PITPRIVY <br /> SEWAGE DISPOSAL! FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cab1e._Too.l_ Dia. of Well Excavation _ <br /> Domestic/private .1Dr.i1led 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 �'' a r` - Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:'--'-' Q•Sta�e Work"Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ___' <br /> Describe Material and Procedure <br /> k <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 ownerkor-licensed agent' s°,s gnature 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 CALLPQR A GROUT WPECeTION PRIOR TO GROUTING AND A F NAL NSPECTION. <br /> SIGNED `r TITLE: DATE: <br /> DRAWPL T PLTN_ ON REVER E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / ' <br /> ADDITIONAL COMMENTS: <br /> PHASE �II :GROUT; -INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B BATE t1l Y <br /> i <br /> Pu 1 A9A Ro„ 19_77 1/7 8 M <br />