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JAN JUAL�lliN LU(;AL. FitHL I ti UlJ I Itl[, f - — <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> k <br /> �- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-F-2-2,?- <br /> This <br /> ssuedg_ _This Permit .Ex ires 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 /> dnd/or install the work herein described. This application is rude in compliance with San <br /> ..oaquin County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health <br /> ''strict. <br /> EXACT STREET ADDRESS Sifyv,w CITY/TOWN <br /> Owner`s- Name Phone <br /> Address <br /> Ci tyXSC <br /> Contractor's Name .�.�Si ,, License#.2 Phone <br /> _YS CERTIFICATE OF WORKMAN'S C011-IPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES tdO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 i <br /> PUMP INSTALLATION W PUMP REPAIR❑ - PUMP REPLACEMENT [� <br /> DISTANCE 'TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD USSPOOI./SEEPAGE PIT OTHER <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary , `Type of Grout i <br /> Disposal Other a Other Information <br /> _ Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor _,.,®_ - <br /> Type of Pump H.P. 02 - <br /> PUMP REPLACEMENT: ❑ State Work Donee <br /> PUMP_ REPAIR: _ -._.- _ _. <br /> -,❑State. Work Done <br /> DESTRUCTION OF WELL: Well Diameter - - <br /> Approximate Depth <br /> Describe,Material and Procedure <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 in such manner as to become subject to Workman's Compensation <br /> laws�of California. " <br /> I WILLzCA `FOR A GRO ThNSPECTION PRIOR TO GROUTING AND A FI L INSPECTION. <br /> SIGNED .. ' TITLE: DATE: )?-/— <br /> ` DR W .PL T PL N ON REVER E SIDE <br /> ^ r a <br /> ' a FOR DE ARTMENT USE ONLY <br /> ;Z42 <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE /7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 4-I:."GROUT 'INSRECTIQN RASE I II INAL I PECTION <br /> INSPECTION BY �;'`` ri: DATE_ -a �/�- INSPECTIONor <br /> BY ATE <br />=H 149A Rn„ 17_'77 F <br />