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r SAN JUHQUfN L.U(:HL HtHLI N iJ151 Kll.1 <br /> FOR SIC£ USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7$7Qjj <br /> Telephone: , -('209) '466-6781 <br /> ' <br /> -- _ f ' Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex i.res 1 Year From Date Issued <br /> Complete In Triplicate) 2-/ - l n �l/ <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 /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> District. vZ.S�3 <br /> EXACT STREET ADDRESS <br /> Owner's Name 0 Phone 17V .- <br /> Address C City <br /> Contractor' s Name ""Li cens-e <br /> #4g373 Phone <br /> ' F <br /> IS CERTIFICATE OF WORKMAN'S C111PENSATIOIN INSURANCE ON FILE .WITH, SJLHD? YES ✓ '40 <br /> _TYPE OF WORK (Check) : NEW WELL0i0£E .,--- ---,-- ---- <br /> PEN ❑ - RECONDITION [' DESTRUCTION <br /> 'WELL CHLORINATION ❑ WEtL- ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATIONZI-1 'PUMP REPAIREr PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: 'SOT IC 'TANK ``' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -;kPR �OP. ERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED—USE--' TYPE OF,!WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel-7-Pack Depth of Grout Sea <br /> Cathodic Protection Rotary- Type of Grout <br /> Disposal --_ Other, Other Information <br /> Geophysical. Surface Seal Installed by: <br /> PUMP"I'NSTA-LLATION: - Contractor <br /> Type- of'Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done, . <br /> PUMP REPAIR: CRState Work Done ` ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and, Procedure <br /> k <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 <br /> Health District. Home owner or licensed a ea't' s s%ig ature certifies the following: <br /> "I cer-tif .- e�-perfo a.nce�o-f- h ,.wo.r_ fa._ _w.hi.c thi_s.� erm_i- ism- . .ue.d-;\I:sh 1_1�. <br /> .no m oy per o 'n suc a a� o bVcc ie a to kman's C m nsaM on� , i <br /> laws o al if i tnti '�D� I -�' <br /> I WILL CALL R U INSP T P I GR ND A FINAL INSPECTION. Y <br /> SIGNED I TITLE: DATE: t. <br /> -D T D L11 N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II� GROUT• INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY "'DATE, r . :;" INSPECTION BY r.¢� DATES 7� <br />