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�_. SAN JUAQUIN LUGAL HLALIH UISIRIGIrFO�I -- <br /> FFhi_E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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. <br /> EXACT STREET ADDRESS / �1� ��� _ CITY/TOWNe_�s-,_,,/,� <br /> Owner's Name /?, _ , Sl y,, Phone q,-?k - 22d,� <br /> Address—' 12w City <br /> Contractor's Name License#?e?&� Phone .Z f �7_,t1d <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIQM IPdSURANCE ON FILE WITH SJLHD? YES_ NO <br /> TYPE OF WORK (Check) : NEW WELLf4 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER(. <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES 1PIT PRIVY <br /> SEWAGE DISPSO ALS FIELD _- CEL/SEEPAGE PIT OTHER-- <br /> • PROPERTY LINEA)(PRIVATE DOMESTIC WEL6� PUBLIC DOMESTIC WELL ---- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r-- <br /> Industrial 7 Cable Tool Dia. of Wel Excavation /_2 <br /> Domestic/private Drilled Dia. of Well Casing ti <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal Ud <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: ocur,r <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 accordance <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 FOR A GROU ` IN PEC PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E ==,f, <br /> TITLE: DATE: <br /> �DRAW PLOT PLAN. ON REVERS IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPA LICATION ACCEPTED BY 1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III fpINAL I14SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />