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t- ✓ SAN JUAQUIN LUUAL HLAL I h U1J I K1(,I <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No 7g isms-" <br /> Telephone: . (209) 466-6781 <br /> i <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 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 /> Joaquin County Ordinance No. 1862 -and. the Rules -and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN-fSCp,(1•t/ _ <br /> ,.r� <br /> Owner's Name Phone. - <br /> Addressgin L)24 <br /> City Vic' ql, --- i <br /> Contractor' s Name.- Li cense Name.--I— Phone <br /> ': S CCRTIrICATE OF WORKMAN'S C01 PENSATIO'N I!ISURA"10E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION C3 DESTRUCTION d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Ei- OTHER <br /> 'L . PUMP INSTALLATION X PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE'S PIT PRIVY <br /> _ .SEWAGE DISPOSAL--FIELD CESSPOOL/SEEPAGE PIT OTHER c <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 /> Domes tic/pri..vate 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 <br /> Disposal T Other Other Information i <br /> L Geophysi-calSurface Seal Installed by: <br /> PUMP INSTALLATION: ` ' Contracto '� ,� �►,fj j <br /> Type of Pump H. <br /> PUMP REPLACEMENT: Q State Work Done f <br /> PUMP REPAIR: ❑State Work Dane <br />- DESTRUCTION OF WELL: Well Diameter 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 accordance <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 WILL CALL FOR A WOUT INSPEC ON PRIOR TO GROUTING AND A FI-W INSPECTION. <br /> SIGNED TITLE: DATE: ���� <br /> DRAW PLFT PL N ON REVERS SIDE <br /> FOR DE ARTME T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADD.ITIONAL COMMENTS:- <br /> PHASE 'II .GROUT INSPECTION . PHASE III F NAL INSPECTION d <br /> INSPECTION BY `DATE { I - INSP ON BY ATE �J <br /> r <br /> ., ,„ <br /> 1 1'70 1) r <br />