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rte` SAN JUAQUIN LUCAL HLALIH U151RIC1 - p <br /> FICE USE: <br /> 1601 E. Hazelton Ave.. , Stockton, CA 95205 Pe ft No. <br /> Telephone: (209) 466-6781 y /6 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER Date Issued a- <br /> This Permit Ex ire's 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.. Thi°s 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. 4 <br /> EXACT STREET ADDRESS J 1107 <br /> 6 ''4' <br /> Owner's Name �•,. <br /> CITY/TOWN <br /> Address " Phone ; <br /> 1 p16� <br /> 1 city <br /> Contractor's Name� 1. .. y�"'�j License# Pf,3 7 t-4�Phone <br /> IS CERTIFICATE OF WQRKtIANIS CORA <br /> P AT 0"1INSURANCE ON FILE WITHSJLHD? YES rao �676 <br /> TYPE OF WORK. (Check) : NEW WELL Ci tEiP.EN'[7 RECONDITION Q DESTRUCTION C] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER ( <br /> PUMP INSTALLATION M PUMP REPAIR 0 PUMP REPLACEMENT g) cJij <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED duTYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Instriall Cablbl e Tool Dia. of Well Excavation_ <br /> _Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven - - Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> Type of Grout <br /> Geophysical Others Information <br /> Surface Sea] Installed k". <br />'UMP INSTALLATION: Contractor <br /> Type of Pumpft N.P. / <br />'UMP REPLACEMENT: IK State Work Done <br />'UMP REPAIR: O State Work Done <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Proce ure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ealth 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 /> WILL CALL FOR A GROUT INSP 0 P TO GROUTING AND A FINAL INSPECTION. <br /> IGNED ITLE: <br /> DR W LOT PL ON REVERSE SIDE DATE: <br /> iASE I FOR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED BY DATE l� 4 ,� <br />)DITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION B <br /> DATE__Z= 7 <br /> 1426 Rev- 12-77 <br />