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5AN JUAQUIN LULAL HtAL I K Ui5 1 K1U 1 <br /> FFICE US£: !ll��� 1601 E. Hazelton -Ave. ', Stockton, CA 95205 Permit No._7,f /[? <br /> - Telephone;; (209) `466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �� i <br /> This Permit Ex ires 1 Year 'From Date Issued <br /> Complete In .Triplicate r <br /> Application is hereby made to the San Joaquin Local . Healt.h District for a permit to construct <br /> and/or install the work herein described.. This application;'is made in compliance with San <br /> L'oafiuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health ' <br /> District. ti <br /> s <br /> EXACT STREET ADDR SS - j �YII�� 1'JLLJW �, ITY/TOW0!,0E0&-M1 <br /> Owner'-s Name__V_ L. Phone <br /> Address City <br /> Contractor'sName �LLicense2V 7702. Phone 6 W 7 - x/'77 J- 4 <br /> a � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI01'2 INS_QRA"ICE ON FILE WITH SJLHD? YES «-�� NO 1 <br /> TYPE OF WORK (Check) : NEW WELL <br /> M—___`DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [J <br /> DISTANCE TO NEAREST: SEPTIC TANK/�, SEWER LINES(-SO ' PIT PRIVYit//j <br /> SEWAGE DISPOSAL FIELP�4 � CESSPOOL/SEEPAGE PIT / OTHER rl <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ze2 , S_ <br /> c,---6omestic/private 11 ed Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing de <br /> Irrigation gavel Pack Depth of Grout Sea ` <br /> Cathodic Protection rotary Type of Grout C �4� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by:za_&__1:_,2EA I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 'Describe Material and Procedure <br /> I hereby certify. that I have prepared this application and that the work will be done in accbrdance <br /> gith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local € <br /> iealth 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 California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE: DATE: <br /> (DRAW PLOT PLAR ON REVERSE SIDE <br /> . FOR DEPARTMENT USE ONLY <br /> CHASE I :"'�'• Imo () <br />%PPLICATION ACCEPTED BY E DAT I`7 7 <br /> kDDITIONAL COMMENTS : <br /> PHASEfIIiGROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYD�ATE <br /> H 1 a9r, - <br /> R-ot, 1.7_77 Y 7 /7 S2 om <br />