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_fes" <br /> FFICE US 5AN JUAQUIN LUGAL MtALIN U1JIF{1[ I <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone r (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This -Permit Ex ices 1 'Year From Date Issued ) <br /> �. Complete : in 'Triplicate <br /> Application is' hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/.or install the work herei.n .descri-bed.. This application is made in compliance with San <br />%'oaauin County .Ordinance .,No. 1862 and Ahe Rules and Regulations of, the Sa Joaqui.n . Local Heal h ; <br /> District. ®� <br /> EXACT STREET 'ADDR ('/� <br /> Ess CIO/ed <br /> Owner's Name <br /> L <br /> Address Phone <br /> r C i' <br /> � C i.ty. <br /> Contractor's Nam r, nse - hone �5� - ( y <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI0,N INSURAt10E ON FILE WITH SJLHO? YES 1110 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ® DESTRUCTION su <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 93—�_PUMP .REPAIR 0 PUMP REPLACEMENT <br /> r <br />)ISTANCE TO NEAREST: SEPTIC TANK ,-.5��SEWER LINE" PIT PRIV '� .S� i i <br /> SEWAGE DIS SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPEC F ATIONS <br /> Cable Tool Dia. of Well Excavation } <br /> �mestic/private '� Drilled Dia, of Well Casing <br />_____Domestic/public Driven <br /> Gauge of Casing f <br /> Irrigation -gavel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surfa Seal Instal _.by: <br /> UMP INSTALLATION: Conitracto.r. <br /> Type of u p N.P.� <br /> -� <br /> UMP REPLACEMENT; []State Work Done <br /> UMP REPAIR: ❑State Work Done fi <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth ? <br /> Describe Materia ,and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance`' <br /> ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br />�alth 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 alifornia. <br /> WILL CAL F R A GROUT NSPECTION I R TO ROUTING AND F NAL INSPECTION. <br />:GNED TITLE: DATE <br /> DR W PLOT PL N ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> IAS E I <br />'PLICATION ACCEPTED BY <br /> iDITIONAL COMMENTS: DATE_ - 375 <br /> PHASE II GROUT_ INSPECTION <br /> SPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DAT <br />-1426 Rev.. 12-77 <br />