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F 5 <br /> SAN JOAQU.1N LUGAL HLAL I H Ulb [KiL I <br /> FFICE,,.USE:_ /' 1601 E. Hazelton Ave. , -Stockton, CA 95205 Permit No. �3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -5 - <br /> r r. <br /> This 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 /> 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 ADDRESSg, , I IFIZCITY/TOWN&,c <br /> Owner's Name Phone_2,g9• - q6 <br /> Address Ci ty&AW.�Cdc ¢ S3�L <br /> Contractor's Name License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURA? F ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLEZ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0WELL ABANDONMENT ❑ OTHER fJ - tri <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK/gip SEWER LINES PIT PRIVY -- cr <br /> SEWAGE DISP SAID FFIELD CE5�OL/SE£P� IST �-- OTHER — � <br /> PROPERTY LINO-tPRIVATE DOMESTIC WELDG PUBLIC DOMESTIC WELL <br /> S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation —K—Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout &c <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: rqdill <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r]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 C L' FOR GROU IN ECT RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D W PL N ON REVE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> PPLIC TION ACCEPTED BY �(_ DATES <br /> ADDITIONAL COMMENTS: —� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES 22-7d"" INSPECTION BY DATE ,S-a-S- 76 <br /> EH -1426... Rav_ 19-77 ��� / �'' � _ 1 /7R ��C l <br />