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G�NaA�'7_�,AN JUAQUIN..LUCAL ,HtAL I H U1 I KU,IFOB Permit No. �$ ' <br /> FFICE USE: 1601 E. Hazelton Ave. , :Stockton, CA 95205 <br /> Telephone; (209) '466-6781 Date Issued os? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex Tres 1 Year 'From. Da e Issued ; <br /> Complete In Triplicate <br /> Joaquin Local Health District. for,,a permit to construct <br /> Application is hereby made to the San q <br /> and/Or install the work hereinj,described. This application is made in compliance with San <br /> uoacluin County Ordinance fro. 1862 and the Rules, .and Regulations of the San Joaquin Local' Health <br /> District. <br /> J4�1 <br /> EXADT: STREET ADD SS q b CITY/TOWN <br /> #. , . Phone 3 0 ! <br /> Owner' s Name f , <br /> City <br /> Address :: <br /> Contractor's Name Li cense#/fd.1 3 73 Phone ! -� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES. u NO <br /> MI <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION F-1 v <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 `OTHER <br /> PUMP INSTALLATION .. PUMP REPAIR❑ m PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: `SEPTIC TANK SEWER LINES <br /> ECESSPOOLPIT PRIVYPIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE . -. PRIVATE DOMESTIC'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - Ir-TY-PE-OF­WELm ­- CONSTRUCTION SPECIFICATIONS m <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 TepehoffGroutt Seal <br /> Cathodic Protection Rotary yp --- <br /> Disposal Other;..-_. <br /> Other Information <br /> Geophysical - Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor _ <br /> Type of'Pump. orH.P. <br /> � ova <br /> kPUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELLY --Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> `fL <br /> ° I hereby certify that I have prepared this application and 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 /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person inIsuch manner as to become subject to Workman' s Compensation <br /> I laws of California." ' <br /> I WILL CALL OR.A GROUT I PECTION P OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED f -:� TITLE: DATE: <br /> a R .W�P,LOT PL N .ON REVERSE DE <br /> iOR .QEPARTMENT USE ONLY <br /> 'PHASE I <br /> ,APPLICATION ACCEPTED BY QATE <br /> ADDITIONAL COMMENTS:, , <br /> PHASE II :GROUT, INSPECTION PHASE III FINAL- INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �'l DATE 9-LI- <br /> k <br /> 1/78 2M/ <br />