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:1* ' t <br /> SAN-11 AQUIN LUGAL HtAL I H Ul5 I kll;i } <br /> USE: 1601 E. Hazel ton Ave. , Stock-ton, CA 95205 Permit No. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued L- <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 ",0. .1862 and the Rules- and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS C� CITY/TOWN <br /> Owner's Name 9EPhone g6§?— <br /> Address Z City / - -- <br /> i <br /> Contractor' s Name_ � � (� `�,�fl�/_�r_ License# hone_ 2-6Y-3 '57 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION 1% DESTRUCTION ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST.:_..._ -SEPTIC TANK---j-,57-:.SEWE.R....LINES 7 �=PIT PRIVY <br /> - SEWAGE---DISPOSAL-FIELD----CE-S-S-POOL/SEEPAGE--PIT-----w'=OTHER ---�- t <br /> PROPERTY LINE�ePRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL _e' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialX Cable Tool Dia. of Well ExcavationSj <br /> Domestic/private Drilled Dia. of. Well Casing <br /> Domestic/public Driven Gauge of CasingI,i/Ize /®'�__/� <br /> Irrigation Gravel Pack Depth of Grout Seal `- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor v <br /> Type of Pump H.R. <br /> PUMP REPLACEMENT: Q State Work Done :., �. . <br /> PUMP REPAIR: ❑State Work Done 4'e <br /> DESTRUCTION OF WELL: Well Diameter . Approximate' Depth" <br /> Describe Material and Procedure <br /> I hereby certify that I have j-repared this application and that'`the work willa done in accordance <br /> with San Joaquin County Ordinances , State Laws , and 'Rules and Regulations of'td San Joaquin Local <br /> Health District. Home owner or licensed agent' s signatdre:: certi-fies the folio ing: <br /> "I certify that in the performance of the work for:.jwh.ic-h ;th:i s;'.permi t is issued, I shall <br /> not employ any person in ,sucYi Marn-er,' a5' to"beco,4-subject Ito' Workman's Compensation <br /> laws of California." <br /> I WILL CALL F R A GROUT INSPECTION PRIOR TO GROUTING. AND A FINAL INSPECTION.It I <br /> SIGNED TITLE: DATE: 7 � <br /> DRAW PLOT PLAN ON REVERSE SIDE a <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY J DATE- <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7- <br />'`ru irtl)r n,... zo -77 1 179 2M <br />