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.MtvU/t�uiit �UUGL„IICf 1i..111 UlJll\1V1�.� <br /> FF ';,E USE: 1601 Hazelton Ave. , Stockton, CA D5 Permit No. - .'3 <br /> ,-.- Hazelton <br /> Telephone: (209) 466-6781 `J <br /> Date -� /0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Issued` � <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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. 9 sr s', C7Q+A/?L/..�/f� ��� <br /> EXACT STREET ADDRESS L CI /TOWN T <br /> Owner's Name !"y ,� `� ( P� Phone <br /> r <br /> Address city <br /> Contractor's �4—S�Yu 1�C License#• Phone4t,- <br /> IS CERTIFICATE OF WORKMAN'S C;IMPENSATION INSURANCE ON FILE WITH SJLHD? YES�� NO <br /> TYPE OF WORK (Check) : NEW WELL CM DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION/Q PUMP REPAIR❑ PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 'r rh <br /> s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -. PRIVATE- DOMESTIC WELL 24� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c <br /> Industrial Cable Tool Dia. of We 1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal 1nsta ed by: <br /> PUMP INSTALLATION: Contractor ( � poi ,,1g's * ,%--rUlcC Z/Lc <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: ❑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 accordant <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 CALL FOR A VOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �,",� � , TITLE: DATE: <br /> (DRAWN ON REVERSE SIDE) <br /> R DEPARTMENT- USE ONLY <br /> PHASE I --� <br /> APPLICATION ACCEPTED BY DATE----7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT I PECTION PHASE III FIML INSPECTIO <br /> INSPECTION BY t�z. DATE / INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />