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5AN JUAQUIN L.UUAL. HLAL I M Ulf )I iU I <br /> r FOR USE: 1601 E. Hazel ton fAve. , Stockton, CA 96205 PermitNo. '1 ' <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> r This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate ry <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 Ordinanc No. 18 2 and t Rubes and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADORES CITY/TOWN <br /> Owner' s NamePhone <br /> : Address City <br /> Contractor' Name t`1{�F1,I�,t. . r�. S „� - -� _ License#3 Phone. � <br /> TS CERTiFiCATE OF-140PK�iAPJ`SI CO�,iPEPJSATiO'J INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELLIK DEEPEN ❑ RECONDITION ❑ , DESTRUCTION[] <br /> ` WE.LL'.CHLO.RI NATION 0 -WELL,ABAN0ONMENT,0- -iOTH,ER ❑ _ ----- -- <br /> T PUMP INSTALLATION ❑ . PUMP REPAIR❑ 'PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKaQ�� SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD r CESSPOOL/SEEPAGE PIT OTHER q <br /> PROPERTY LINE - PRIVATE DQMESTIC WELL,� PUBLIC DOMESTIC WELL <br /> r INTENDEQ USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> IrdOstrial _Cable Tool Dia. of Well Excavation " <br /> Domestic/private Drilled Dia, of Well Casing q"®. IQ,.' <br /> Domesiri c/public . Driven Gauge of Casing ) <br /> . .... ... .. <br /> -Irrigation, Gravel Pack Depth of Grout Sea ' <br /> Cathodic-O r``otection Rotary -Type of Grout <br /> _iDi sposa.l .,� `-� . Other Other Information 1 <br /> - <br /> -Geophysical Surface Seal Installed by: oAZJ&A&n:� <br /> PUMP JINSTALLATION.: Contractory <br /> -:- Type of Pump H.P. <br /> PUMP REPLACEMENT: ;-' [I-State- Work ,Donee" r~ <br /> PUMP REPAIR: e-CIState Wdrk -Done <br /> DESTRUCTION OF WELL: Well Diameter `` � Approximate Depth <br /> Describe Materia " and Procedure <br /> I hereby certify -that I have prepared th'i s °application and--t#'6t the work wi 14-_be-done i 6."accordan <br /> with San Joaquin County Ordinances , `Sta"te .Laws , and Rules and °Regulations of the—San Joaquin Loca <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 i <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 GROUT INSPECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED T..ITWLE: DATE: <br /> DAT . <br /> DR W PL E <br /> LSSI <br /> ' <br /> FOREPARTMENT USE ONLY <br /> PHASE I d <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTIINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION- BY .'DATE INSPECTION BY DATE <br /> EH 1426 Rev- 12-77 1/78 2M <br />