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:SAN JUAgUIN LULAL;.HtALIH U1JIKI[.I -- <br /> FFICE USE: 1601 E. Hazei'�ton Ave. , Stockton, CA 95205 -Permit 'No. - _o <br /> Telephone: (209) 46,6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit .Ex ires . l'Year From 'Date ' Issued N <br /> Complete `In Triplicate) , 02—C —raa—o3 <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 />�oaq:fi:n County- Ordinance No. 1862. .and the:Rules and' Regulations 'of the San Joaquin Local .Health <br /> District.:/5lPo'o rv• sc.�:�' AlQR.TN. 0� <br /> EXACT STREET AD'DR S r/� CITY/TOWN <br /> d�- --- <br /> 04 <br /> Owner's NameJ Phone� (p �1. 1 <br /> Address f _ i C;ty. ` - <br /> L�2o <br /> Contractor's Nae u = Li cense Phone -- s `� <br /> IS CERTIFICATE OF WOWIAN'S COMPENSATION INSURANCE ON FILE WITH SJ"LHD? YES N0,��-� <br /> TYPE OF WORK (Check) : NEW WELL C� DEEPEN 0 RECONDITION ❑ RUCTION[D <br /> WELL..-,CHLORINATION 0 WELL ABANDONMEN OTHER 0 <br /> P.L MP 'INSIALLATION ElPUMP REPAIR PUMP REPCACEMENT 0 �41 <br /> DISTANCE^,JO NEAREST: SEPTIC TANK—" SEWER LINES .. PIT PRIVY u S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE-DOMESTIC. WELL , PUBLIC .DOMESTIC WELL <br /> INTENDED USEV ~. TYPE OF WELL CONSTRUCTION SPECIFICATIONS -` <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f —Domestic/private Drilled Dia. of Well Casing_ C <br /> amestic/public Driven Gauge of Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical -""':"Surface Se Installed b : <br /> PUMP INSTALLATION: Contractor-- 9� r =% <br /> Type-of Pump N.P. <br /> PUMP REPLACEMENT: [] State Work Done-, <br /> PUMP REPAIR: OState,Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depthe"' <br /> ' Describe kkie.ri.al and Procedure <br /> - <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 I <br /> Health District. Home, own'ef `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 ,.a,ny person in such manner as to become subject to Workman 's Compensation <br /> -laws of , l i fora i a.lr <br /> I WILL CAL FOR A GROUT INSP ,ON P ,OR TO GROUTING AND INAL INSPECTION. f" <br /> SIGNED TITL"E`• ' <br /> DAT 12;1 <br /> , <br /> - PLOT PL N ON REV IQE' - <br /> PHASE I FO DEPARTMENT USE ONLY N <br /> APPLICATION ACCEPTED DATE'? <br /> ADDITIONAL COMMENTS,: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - p <br />-H 142A Rail 17-77 s• .1 /79 . 2M .. <br />