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JAN JUAQUIN,LUGAL „HtALIH UIJIKIL-, '�yI Permit No. O <br /> FOR OFFICE USE: 1601 E. Hazelton :Ave. , Stockton,. CA 95205 <br /> Telephone:`1 (209) :466 6781 Date issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit' Ex ires . 1 Y.ea-r. From. Date Issued h <br /> xComplete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or installthe work herein described -This application.-is..made iri compliance' with San <br /> ,'oaqu i n County ,Ord i Hunte . No.. 186 and _tfhe Rut-es,and .Regul ati ons of the.San Joaquin Local Health <br /> District. L <br /> EXACV STREET `ADDRESS CITY/TOW <br /> ,Pf, . Phone l <br /> Owner' s Name <br /> City <br /> Address Q <br /> Contractor's Name <br /> . License Phone � <br /> TS CERTIFICATE OF WORKMAN'S C0MP -'_NSATI0'1 I"1SURANCE ON FILE WITH SJLHD? YES (ANO <br /> TYPE OF WORK (Check) : NEW WELL Ll--�_DEEPEN ❑ RECONDITION [D <br /> DETI N� <br /> WELL CHLORINATION LCI OTHER <br /> (T <br /> PUMP INSTALLATION Er PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SA FIELD CESSPOOL/SEEPAGEPUBLIC DOME�TICRWELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />' �ftmestic/p.rivate Drilled Dia. of Well Casing zf �-y , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack - Depth of Grout Sea <br /> Cathodic Protection o�a-ry Type of Grout <br /> 7D.isposal Other i Other Information <br /> Geophysical �' ± Surface Seal Instal ed by: <br /> 1 <br /> PUMP .INSTALLATION: Contractor ' H.P. <br /> Type of,Pump <br /> PUMP REPLACEMENT: p State. Work� Done <br /> PUMP REPAIR: 0,S'tate WoW.Done" <br /> { � - Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe MaterIAT and Procedure . <br /> r I hereby certify that" I have prepared this application <br /> 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 /> k "I certify that in the performance of-the work for which this permit is issued, I shall <br /> I not employ any person in such manner as to become subject to Workman' s Compensation <br /> " laws of California.” E <br /> I WILL CALL ORA GROUT INSPECTION PRIOR TO GROUTING- AND A FINAL INSPECTION. <br /> SIGNED r. * TITLE:' DATE: <br /> . v DR PLUIPLAN -ON REVERSE SIDE <br /> - � FOR DEPARTMENT USE ONLY, <br /> PHASE I Y DATE_6,, <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL' COMMENTS: <br /> PHASE "11 GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY _DATE k t � INSPECT.IQN..BY, DATE <br /> L8 2K <br /> rW 1 d9ti Rcv.. .19_77 .. . <br />