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V <br />�- JAN JUAQUIN IwUf,AL HtAL I H U1J 1 KiL, 1 <br /> EOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, ,CA 95205 Permit No. 7"r-- %�� i <br /> Telephone: (209) 466 '6781. I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued —This Permit Expires 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 /> , oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> D4strict. <br /> EXACT STREET ADDRESS & CITY/TOWN Z&A4a.-a <br /> Owner's Name B nA Phone F3t9--,2_9 9 <br /> Address City -- <br /> i <br /> Contractor' s Name �; '_, T ,.� License# ® Phone �j <br /> _rS CERTIFICATE OF WORKiIAN'S COMIPENSATIO1111 I"1SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORk (Check) : NEW WELL❑ - DEEPEN ❑ RECONDITION ❑ DESTRtICTTON[� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP-INSTALLATION -0 PUMP REPAIR® PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER , I <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 /> Irri-gati-on, _ Gravel PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type, of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface ,Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r7 State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin_ County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br /> Health District. Home awner-or licensed agent' s signature certifies the following: <br /> "I certify that in the performance,o.f the work for which this permit is issued, I shall 1 <br /> not employ any person in such manner as to become subject to Workman' s Compensation I <br /> laws of California. " <br /> I WILL CALL OR A GROU INSPECTION PRIOR TO GROUTING AND AK-INA6 INSPECTION. <br /> SIGNED TITLE s DATE: R<2S�7F <br /> DR W _PLOT PLA ON REVER E- .SIDE <br /> PHASE I <br /> FOR DEPARTM NT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE1'7J;'- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL NSPECTIO • i <br /> INSPECTION BY DATE N INSPECTION B DATE <br /> 1 <br /> Cu 1A0L n.... In Tom- L97 i 1-74 1AX <br />