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Will JUAqUIR UUA& MLMLIh U131KIUI <br /> FOR OFFICE USE: 1601 E. Hazelton!, 'Ayl ."--Stockton, CA 95205 Permit No. :Zgd- <br /> 11:A I.?, .' � x(20'9`}'-4b6-6781 <br /> " "� " - - sp <br /> Tel,p ne-f� �(209)�'-466-6781 <br /> ' 1 <br /> APPLICATION FOR'-WELL CONSTRUCTION OR PUMP PERMIT Date Issued `3/ 7 <br /> Thi-s�-Permi-t. Ekp-ir6s' IFI-Yea'r'�Frbm Oate`4tsUek-, <br /> (,'Com -, 8. 6 'Ilff-Trilpl-, Cate'- ,'J:v I <br /> V3 !) <br /> Application is hereby made to the S cal . Heg <br /> a 410 th" r-..c permit t to,,qons'trkt <br /> and/or,'_jj�r) n Joaquin ica on is mad6, in compif ncjel `W't 'I <br /> _�ta,13,J-Ke,wor,k .�prein 4escribe S �a i h 'San ti <br /> Ap'L <br /> gu f focal' Heal th' <br /> t�oaqu 1 n_,,Cqup� 1$L "Re" l(a!f"offs the Joaquin,y,0 rdi i n��.,j Na u- s and <br /> I u .:rl e V <br /> nlistrici. <br /> EXACT <br /> .71 <br /> 6ADDRES 9 ClITY .TOWN_'1. <br /> D e <br /> Owner's'Na- "A -3 k6he. <br /> Addres.s City <br /> Contractor's Name License# Phone <br /> TS CERTIFICATE OF WORKMAN -S CO'..IPENSATIO,"I INSURA1.10E ON FILE WITH SJLHD? YES NO <br /> TYPE .OF WORK (CheckY: NEW WELL 0 DEEPENO RECONDITION ❑ DESTRUCTION"--- <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 .OTHER Fj <br /> PUMP INSTALLATION El PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> DISTANCE.TO NEAREST:,: SEPT' IC';TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYLINE —PRIVATE DOMESTIC WELL PUBLIC 'DOMESTIC WELL - <br /> 1NTEND9D- ELSE TYPE: OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing' <br /> Driven Gauge of, Casi <br /> Domestfc/Rubl:ic Gravel Pack Casing <br /> Irrigation D6pth' of Grout Seal <br /> Cathodic Protection —Rotary ,' -'Type' of Grout <br /> Disposal Other OtherlInformation <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ! H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter bar Approximate Depth 06 <br /> Describe Materia and Procedure <br /> I hereby certify ,that I have prepared this application and, that the work will be done in accordance <br /> with San Joaqyin :Coutity Ordinances , .State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. '. Home owner or licensed a9ent'.s signature certifies the following: <br /> "I certify .tha,t in the performand,e of the Work for which this permit is issued, I sh6ll <br /> not'employ any in such manner as to become subject` to Workman's Compensation' <br /> laws of Cal ifPr.nja." <br /> I WILL CALL FOR k. GROUT INSPECTION PRIOR TO GROUTING AND A. FINAL INSPECTION. <br /> SIGNED TITLE: ,. _�DATE. <br /> DRAW-PE6T7PLTff ON REVERSE' SIDEr- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY /<U DATE 2 <br /> EH 1426 Rev. ..12-77 , <br />