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°r SAN JOAQUIN LOCAL Ht=ALIM WbI K1LI <br /> FOR FFILE USE: , .StocktonCA 95205 Permit No <br /> 1601 E. Hazelton ..'Ave. , <br /> Telephone: (209) 4.66-67811 <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER Date Issuedg- <br /> ' MIT <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> Application is herebymade to the San n Joaqu7n Local Health District for a .permit to construct <br /> i and/or install the work herein described. This application is madein compliance with San <br /> Ioaquin County Ordinance. No. I862 and the Rules and Regulations. of the San Joaquin Local Health <br /> Cistrict. <br /> EXACT STREEEHTADDRESS h. CITY/TOWN <br /> Ow <br /> per' s ameY <br /> ��f S t 4 Phone <br /> Address - - -. - City - <br /> E _ <br /> Contractor' s Named , License#�Z.&t? Phone �, . . . <br /> — e. <br /> 'S CCRTiFICATE OF WORKMAN'S C0�mPENSATION INSURANCE ON FILE WITH SJLHD? '�-YES_' <br /> TYPE OF WORK u-(Check).: NEW WELL L DEEPEN p RECONDITION ED DESTRUCTIdN p _ _'_ <br /> WEL'L• CHLORINATION 0 WELL ABANDONMENT Q OTHER W( <br /> PUMP INSTALLATION Da PUMP REPAIR❑ PUMP REPLACEMENT 11,. 4.6 <br /> .i <br /> DISTANCE TO NEAREST:! SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SE.EPAGE FI _T OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial - .,.-Cabl-e,Tool--:-.�-�- ..—D•i-a —of-'Wel-l- Excavation- <br /> va <br /> Domestic/prite Drilled Dia, of Well Casing M <br /> Domestic/public �.Dri'ven` Gauge of Casing { <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> _PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: . <br /> _- [ State Work Done �. <br /> DESTRUCTION OF WELL: Well Diameterte <br /> Describe Materia and Procedure Approximate Depth <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 /> jaws of California. " j <br /> I WILL CALL F A G OUT IN CT N PRIOR TO GROUTING AND A FINA�INSPECTION. <br /> SIGNED TITLE: - DATE: � r <br /> 1: <br /> DRAW PL T L N ON REVS S SIDE <br /> .a FOR DEPARTMEN USE ONLY . <br /> PHASE I s - <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS.:; <br /> PHASE II GROUTINSPECTION ,r PHASE I IP INAL,;I-NSPECTION- ` <br /> INSPECTION BY DAT€TE INSPECTION BY / �' <br /> ?2 DATE / /r;7, , <br /> tiH 1426 Rev_. 12-77 - <br />