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_ 5AN JUAQU IN LUI.AL HLAL I H U1J 1 Kl U 1 <br /> OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. <br /> xvtiT Y-zr, Telephone:. 1(209) 46676781 <br /> Date Issued 3 <br /> APPLICATION FOR WELL CONST*kq-CTION OR PUMP. PERMIT y - ` <br /> This Permit Expires l �Year From Date Issued <br /> Complete In Triplicate), <br /> A lication is hereby made to1Fthe San Joaquin. Local Health District fora permit to construct ] <br /> pp y a <br /> and/or install the work, herein described. This application is made in compliance with San R <br /> oaquin, County Ordinance No. X <br /> District. 862 and the Rules and Regu.lations, of the- San Joaqqin Local Heath _ <br /> � <br /> EXACT STREET ADORES CITY/TOWN <br /> Phone3 3 - 3 - { <br /> Owner's Name <br /> Address � - City '- '# <br /> Contractor' s Name Li cense# Phone -3 61q <br /> 'S CERTIFICATE`-OF-WORKIIAFJ""S-C'O4;PENSATIO`1-'I'"d5URAlciCE ON`FII E?U1ITH SJLHD? YES '>C— NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ - <br /> V i <br /> WELL CHLORINATION ❑ WELL ABANDONMENTED OTHER❑ <br /> PUMP INSTALLATION 0 PUMP,'REPAIR❑ ; PUMP REPLACEMENT ❑ � G,I � <br /> DISTANCE TO NEAREST: SEPTIC- TANKSO SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS' OTHER ; <br /> n PROPERTY LINE - .PRIV.ATE DOMESTIC WELL U6 ' PUBLIC' DOMESTIC WELL <br /> INTENDED USE TYRE OF WELL '; =CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well' Excavationa " <br /> .Domestic/private ,. Drilled - Dia. of -Well Casing <br /> Domestic/public Driven Gauge of Gasing�� <br /> Irrigation <br /> Gravel Pack Depth of :Grout Seal <br /> }Y Cathodic Protection Rotary � ._.r Yype of Grqut <br /> Disposal .-. FOther. Other InformationI <br /> Geophysical Surface Seal Installed b ->� <br /> f. <br /> PUMP INSTALLATION:_.,_ _ Contractor - <br /> Type 6f Pump <br /> " „p. <br /> PUMP REPLACEMENT: <br /> r]State Work Done <br /> f PUMP REPAIR: .'. ❑State Mork Done <br /> DESTRUCTION OF WELL: Well Diame ` ' Approximate Depth <br /> Describe Material and Proceduro, <br /> . - <br /> I hereby.�,certify that I have prepared., appl"ica'tioh'and that the work will be done in accordant <br /> with San'J,oaqui n County Ordinances , State Laws ;`Wand .Rules and }Regul ations"°ofT-the'Sai��Joaqu.l n local <br /> ' Hearth District. Home owner's o'r. 1-i censed�l,agent' s signature certifies the following: <br /> f I certify that in -the performance_of"the work for which this -per mi t i s .issued, I steal 1 <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 INS$ECT,I;GN! PRIOR TO GROUTING AND A .FINAL INSPECTION: <br /> SIGNED , �t 4 "'_ TITLE.: DATE: <br /> F DR W PLOT 'PL N ON REVS SIDE <br /> 1EIA DEPARTMENT USE ONLY <br /> bd PHASE I <br /> APPLICATION ACCEPTED B M �+ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT I ECTI N PHA EI I FINAL INSPEC I +�* <br /> NSPECTION BY - DATE s¢ 2j INSPECTION BY DATE - /7' <br /> .78 2M <br /> ru4IAnc -1— 17-77 ` <br />