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5AN JUAQUIN LUGAL titAL I H U1J I K1[,I <br /> FFICE USE: ✓1601 E. Hazel t.on'AVe. , Stockton, CA 95205 Permit No. Zz1-_1--# <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ _7 <br /> 4 <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 fora permit to construct <br /> ind/or install the work herein described.. This application is made in compliance with San <br /> 20anji n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Jistrict. <br />_XACT STREET ADDRESS V ` �V CITY/TOWN -� <br />)wner s Name ,� ke42 —/ L/ Phone( <br /> Address.. C1 ty <br />.onLracTar s Name - U� License# Phone 9 y <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION 'I"1SURAl10E ON FILE WITH SJLHD? YES NO <br /> HYPE .OF WORK (Check) : HEW�WELL.L7�_.REEPEN ❑ RECONDITION C3 DESTRUCTION[) <br /> 9 <br /> WELL- CHLORINATION 0WELL ABANDONMENT Q OTHER <br /> PUMP INSTALLATION [9--15'UMP REPAIR❑ PUMP REPLACEMENT ❑ <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation` G'ravel'--Pack i Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout <br /> Disposal t er Other Information <br /> Geophysical urface Se Installed by: - CL <br />'UMP INSTALLATION: Contract " - �C/-c, <br /> Type of Pump H.P <br />'UMP REPLACEMENT: F]State Work Done ' <br />'UMP <br /> .REPAIR: ❑State Work Done <br /> IESTRUCTION OF WELL: Well Diameter Approximate `Depth . F <br /> , Describe Material ana Procedure <br /> E <br /> hereby certify that I have prepared this application and that the work will be done in accordance; <br /> lith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth 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 ifornia. " <br /> WILL CAL F R A GR UT INSPE PRIG TO GROUTING AND INAL INSPECTION. <br /> I G N E D TITLE• DAT / � <br /> URAURP%WV PLOT PL N ON REVERSE-SIDE) <br /> r <br /> FOR EPARTMENT SE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY ry�...,� DATE A 7� <br />,DDITIONAL COMMENTS : <br /> PHASE. II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY . f DATE�j G-/Z 7 <br /> H 1426 -, Rev. 12-77 . <br /> v�� 1/78 2M <br />