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SAN JUAQUIN LULAL- HtALIN Ul�)IKIUI Permit No. <br /> FFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 <br /> Telephone: (209) 466-6781: Date Issued a--��-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From Date Issued ' <br /> I Complete In Triplicate <br /> Application is hereby made totheSan Joaquin Local Health District for a permit to construct <br /> acid/or install the work herein. described. � .This :application is made. in compliance wi.th San <br /> .oaquin County Ordinance .No. .r1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> CITY/TOWN <br /> EXACT STREET AD h SS i <br /> Phone <br /> Owner' s Nance <br /> C i.ty . <br /> Address ' <br /> Contractor' s Name <br /> License `9os3 _ Phone ' S93 <br /> 'S CERTTFTCATE OF WORKMAN'S CD""PENSATIOPI INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check.) : NEW WELL 0 DEEPEN [-] RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT �MP REPLACE ENT 0PUMP INSTALLATION JX PUMP REPAIR❑ , . <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY-LI"NE•- PRIVATE DOMESTIC WELL . -- PUBLIC DOMESTIC WELL Of <br /> INTENDED USt<; TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )(-Domestic/private,,. DrilledDia. of Well Casing <br /> Domestic/public - � Driven Gauge of Casing <br /> Irrigation `` _ —Gravel -Pack Depth of Grout Sea <br /> 'Type of Grout <br /> Cathodic Protection 7Rotary, -- — ti <br /> Disposal —OtherOther Information <br /> Geophysical Surface Seal Instal ed b : <br /> RUMP INSTALLATION: Contractor H.P. i <br /> Type of Pump <br /> PUMP REPLACEMENT: Jn State Work De' <br /> 4.. <br /> PUMP REPAIR: ❑State World Done <br /> DESTRUCTION OF WELL: Well# Diameter Approximate Depth <br /> Describe Material and Procedure t= <br /> I hereby certify that I have prepared this application and that the work will be done in accordar <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locz <br /> Health 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 F A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I SIGNED TITLE: DATE: <br /> y DDRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> h PHASE I DATE 124 <br /> 7 <br /> APPLICATION ACCEPTED BY <br /> '. ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DP DATE <br /> 1/78. 2 r}71 <br /> t - 2 <br />