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ASV JUAQU!N LULAL HtAL I H Ul51 Rh y; <br /> FFICE.USE: 16� Hazelton Ave. , Stockton, CA . 205 Permit No.�, /� 7 <br /> --� Telephone: (209) 466-6781 <br /> Date Issued= > -?. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires I Year From Date Issued <br /> Complete In Triplicate_ <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct ; <br /> ,d/or install the work herein described. This application is made in compliance with San <br /> )anuin County Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health <br /> istrict. <br /> (ACT STREET ADDRESS I0 ht I ftl A V CITY/TOWN <br /> vner`s Name pVC,v .- _ Phone <br /> idress City. <br /> )ntractor's Name )�tE, rt %' 4 1 u,4- S'cLicense# (5_ Phone b !2d <br /> 3 <br /> If <br /> S CERTIFICATE OF WORKMAN'S C0,11PENSATIO'N I1111SURANCE ON FILE WITH SJLHD? YES NO <br /> 'PE OF WORK (Check) :. NEW WELL L DEEPEN 0 RECONDITION ❑ DESTRUCTIONC] N% <br /> E WELL CHLORINATION ❑ WELL ABANDONMENT a OTHER❑ ! <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT 24--. <br /> ISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY J <br /> SEWAGE DISPIELD CES5POOL/SEEPAGE PIT OTHER <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 <br /> Domestic/private Drilled Dia. of Well Casing_ _� <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea \ <br /> Cathodic .Protection Rotary Type of Grout \ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: _ <br /> JMP INSTALLATION: Contractor M <br /> Type of Pump -H.P. <br /> JMP REPLACEMENT: [.State Work Done u ti g u <br /> JMP REPAIR: ❑State Work Done <br /> 'STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> p :alth District. Home owner or licensed agent' s signature certifies the following: <br /> I "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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: 117 .e DATE: -?-Z 7. <br /> kUKAW—PLOT PLANAN RE R SIDE <br /> F R DEP RTMENT USE ONLY <br /> ASE I r <br /> PLICATION ACCEPTED BY ' DATE <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 7 PHASE II FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY DATEIti��g <br />