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5AN JUAQU1N WLAL -HtAL1H Ul�)IKI l <br /> FOR OFFICE t!SE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 465-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 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 herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS d /C� CITY/TOWN � I�<v._ <br /> Owner's Name ZL So . <br /> Phone S - <br /> Address . City <br /> Contractor's Name <br /> License# / Phone fjk-, <br /> IS CERTIFICATE OF WORKf1AN'S COMPENSATION IINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL JXf DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 . <br /> PUMP INSTALLATION M PUMP REPAIR Q PUMP REPLACEMENT Q 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK-5-0/+SEWER LINES -- PIT PRIVY — A <br /> SEWAGE DISPOS4L FIELD -r CESSPOOL/SEEP4GE PIT____, OTHER <br /> PROPERTY LIN V� RIVATE DOMESTIC WELL�± PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation // <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ I <br /> Irrigation Gravel Pack Depth of Grout Sea e <br /> Cathodic Protection Rotary Type of Grout c,reEJ, 2� �. <br /> Disposal Other Other Informattion S .M- <br />'� Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: O State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant( <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the- following:. - <br /> "I <br /> he following:. -"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."- l <br /> N I WILL CALL FOR A GROUT IPE 0 rIOR TO GROUTING AND A FINAL INSPECTION. G <br /> kSIGNED TITLE: DATE: 0 <br /> W PLOT PLAN ON REVER SIDE <br /> FOR DEP RTMEN USE ONLY <br /> PHASE I ,. <br /> DATE <br /> ` APPLICATION ACCEPTED BY <br /> : ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASLOINAiYNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES 76 <br /> f � <br /> 5D 1/78 2M <br />