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- F <br /> r 5AN ,JUAQU1N LOUAL .-HtAL i H U1�)I KiU l <br /> FOR OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: . (209) 466-6781 <br /> 72 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -, ,/-18' <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 /> ,.oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS I CITY/TOWN <br /> Owner' s Name 1/ L _ Phone -- <br /> Address : J0 A& a City 4S - Aelop^2 . <br /> Contractor' s Name_ ; '`7, ,� ��o Al Li cense#.2a Phone_L��/��Lo� _ <br /> 7S CERTTFTCATE OF WORKMAN'S COMIPENSATIOIN I'NSURAINCE ON FILE WITH SJLHD? YES NO <br />_TYPE' OF WORK (Check): NEW WELL-O' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C3 WELL ABANDONMENT ❑ OTHER ❑ � <br /> PUMP INSTALLATION ❑ PUMP REPAIR 9 PUMP REPLACEMENT ❑ �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ . Industrial- _—Cabl-e_-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 t <br /> Disposal Other Other Information <br /> Geophysical tom' urface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: ;, [7 State Work%Done ,. �' 401 � <br /> I _ <br /> PUMP REPAIR: R]State Work Done A <br /> DESTRUCTION'OF WELL: Well Diameter Approximate Depth i <br /> Describe -Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordana <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 GROU INSPECTION PRIOR TO GROUTING ANDA INAL INSPECTION. <br /> SIGNED NTITLE: DATE: <br /> (DRAW PL T PL N ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �ASI <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION' PHASE III f,2NAL INSPECTION <br /> INSPECTION BY DATE /�� INSPECTION BY DATE��P/�, <br />