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_ SAN JUAQU1N•LUUAL HLAL I H Ui51 KIL I <br /> F.FI-CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 10 <br /> - ° Telephone: (209) 466-6781 <br /> ,. Date Issued ' <br /> J APPLICATION FOR WELL CONS ►i�I�ON OR PUMP PERMIT <br /> M This Permit Expires 1. Year From Date Issued <br /> �Q Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal] the work herein described. This application is made in compliance with Sam z <br /> Joaquin County Ordinance No. . 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> CITY/TOWN <br /> EXACT STREET ADDRESS <br /> ! --- <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name <br /> Li cense# Rhone S (/3 <br /> IS CERTIFICATE OF WAMAN'S COtPEN ATIO" I�JSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN Ci RECONDITION ❑ DESTRUCTION[) <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER F-3 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S PIT PRIVY <br /> "' <br /> SEWAGE DISPOSAL FIELD � \ ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE DOMESTIC-WEL-L ----- PUBLIC�DOMESTTC-WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT NS {� <br /> Industrial Cable Tool Dia. of Well Excavation_ <br />.Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation - -Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �- totary Type of Grout <br /> X. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br />'i PUMP REPLACEMENT: [] State Work Done <br />, PUMP REPAIR: Q 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 Joaq.uln 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 bec su %FI <br /> to Workman's Compensation <br /> laws of California. <br /> II WILL CALL O A GROUT INSPECT&N PRIOR TO GROUTING AL INSPE N. <br /> rSIGNEQ TITLE: TE: <br /> 3 (DRAW PL T �PL N ON ERS IDE <br /> FOR DEPARTMENT ONLY <br /> 1PHASE I <br /> I APPLICATION ACCEPTED BY DATE_-�"'3^-� <br /> 'ADDITIONAL COMMENTS: /Q6 <br /> PHASE II GROUT INSPECTION PHASE I , FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES !7U <br /> 1/78 2M <br />