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FF�E USE: t -)AlltiJUwgUily LUCxu htAL i n ul 3 1 KI c l <br /> 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. � / <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �S_ <br /> This Permit Ex i.res :1 Year 'From Date Issued <br /> I Complete n Triplicate <br /> 'I Dss� ��a -a s' <br /> Application is her made to the San Joaquin Local Health District fora permit to construct <br /> j and/or .install the work herein described.- This appl.icati.on is made in compliance with San <br /> Joaquin County Ordimance. No. 1862 .and the Rules and Regulations of-the San Joaquin. Local Health <br /> District. �!.?$�-g !/ ► <br /> EXACT STREET-ADDRESS G(] <br /> Owher's Name - - - <br /> Address' --r- <br /> Phone3 <br /> C;ty <br /> Contractor's Name ,z ,1,� License <br /> Phone . <br /> IS CERTIFICATE OF WORKMIAN'S COMPENSATIOIN IN URA?ICE ON FILE WITH SJLHD? YES td0 <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 `RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER - , <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT ❑ If <br /> DISTANCE .TO NEAREST: SEPTIC TANK�Qf�. SEWER LINES - ��.PIT .PRIVY <br /> SEWAGE DISPOSAFIELD ' CESSPOOL/SEEPAGE PIT -- <br /> - OTHER <br /> PROPERTY LINA-.iPRIVATE DOMESTIC WELLM-L-f— PUBLIC DOMESTIC WELL ---- <br /> INTENDED USE <br /> TY OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Rte`, ' X Cable Tool0Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/publ:ic , Driven " <br /> � gIrri ation � Gauge-of Casing <br /> Gravel Pack Depth of Grout Seal UV <br /> Cathodic .Protection - Rotary Type of Grout <br /> - -Disposal , , --- <br /> Other Other Information 4- <br /> Geophysical `` ! Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump J .P.� <br /> PUMP REPLACEMENT: L7 State Work Done ] <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ? <br /> Describe Material and Procedure Approximate Depth <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 <br /> not employ an Permit is issued, I shall t <br /> P y y person in such manner as to become subject to Workman 's Compensation <br /> lawslof California." <br /> I WILL CALL FOR GROU I P T N PRIOR TO GROUTING AND A FINAL INSPECTION. <br />�IGNE � � TITLE: <br /> DATE: <br /> DR W PL T PL N ON REVERT DE <br />'HASE I 1 FOR DEPA-RTME14i USE ONLY <br /> PPL LIGATION ACCEPTED BY DATE <br /> @DITIONAL COMMENTS �'�-�• _ <br /> t <br /> PHASE II GROUT .INSPEGTION PHASE I------------- <br /> II INA INSPECTION: <br /> NSPECTION BY DATE <br /> INSPECTION BY DATE a <br /> H 1426 Rev. 1247 - - <br />