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5AN JUAQU1N."LU.I;AL,.-MtAL1 hUibli# ll. l <br /> ,�OR _QFFICE USE: 1601 E. Hazel ton. Ave, ,FStockton, CA 95205 Permit No. <br /> 4; Telephone:; (209) 466-6781 My - <br /> APPLICATION <br /> FORWELL CONSTRUCTION OR PUMP PERMIT. Date Issued1. <br /> This Permit Expires 1 Year From Date Issued` <br /> Compl.ete In Trip 'i cate <br /> Application is hereby made to the San Joaquin Local Health- District fora permit toconstruct <br /> and/or, install. the�.work-:herein described.. This.-appl.ication is ,made. in compliance with San <br /> .'oaquin- County Ordinance No 1862. and the .Rul,es and Regulations, of the San .Joaquin. Local, Health <br /> District. c;;L67 <br /> EXACT -STREEf ADDRESS 2,6 ,57- �/y CITY/TOW <br /> Owner' s _Name. PhoneO 1 <br /> Address _ City <br /> Contractor's Name .� Licenset? Phone <br /> I F a 1 F. " INSURANCE .? <br /> S CERTI ICATE OF WORKM'Atl S CO�IPENSATIO,! INSURANCE ON FILE WITH SJLHD. YES l------;�O <br /> TYPE OF WORK (Check) : NEW WELL GQ DEEPEN❑ RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION Er PUMP REPAIR p PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK Ile SEWER LINES_ PIT PRIVY <br /> SEWAGE DISP SO AL FIELD /S-p CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS E <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r----Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven;,`, Gauge of Casing <br /> Irrigation O ravel Pack Depth .of Grout Seal <br /> Cathodic Protection _ teary- "Type of Grout �- <br /> Disposal r Other Other Information <br /> Geophysical ` _ Surface Seal Instal ed b : <br /> PUMPINSTALLATION: Contractor <br /> 4 Type ofj Pump H.P. <br /> �t <br /> rPUMP REPLACEMENT: ❑_StateFWork Done <br /> PUMP REPAIR: �❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descri be-.Materia an Procedure - �- y -- <br /> ,r <br /> I hereby certify that I 'have prepared this application and that the work will be done in accordanc( <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 certify that-iri'the performance of the work for which this permit is issued, I shall <br /> not employ,•anysperson in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL LORA GROUT INSPECTION PRIOR TO GROUTING AND�A. FINAL INSPECTION. <br /> SIGNED " pL�. TITLE: DATE: <br /> 42 <br /> .E (DRAW PT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E .i <br /> APPLICATION, ACCEPTED BY DATE <br /> ADDITIONALf 6MMENTS: <br /> 0,/ PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE_ ' INSPECTION BY D TE , 7 <br /> _ C; , <br /> r EH 1426 Rev. 12-77 _. _a # ' `: ' _ _ 1-/78 2Mo <br />