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I Kll,I <br /> N JUNI�UiN kU(:NL tikHl.l ! ui. . <br /> - OFFICE USE: 1601 Hazelton Ave. , Stockton, CA {' 5 Permit No. <br /> + Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued `507x' f <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 arid. Regulations of the San Joaquin .Local Health <br /> District. ,` <br /> EXACT STREET'ADDRESS_;.2- J21,�s 2P CITY/TOWN° , <br /> ! <br /> Owner's Name_ I ,�L�azJ /{ - Phone <br /> aAD <br /> G Address �a Ci ty o1 <br /> Contractor' s Name J a� Li cense# ,3 Phone <br /> ?S CERTIFICATE OF WORKMAN'S COMIPENSAlTION INSURA"JCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR DO PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 /> -I-rrig.a.ti.on— l Pack -- ------Depth--of-Grout---Se-a---- ---- - -- - - --= <br /> j Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> ii 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 /> j 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE: DATE: <br /> DRAW, P - T PLAN ON REVERSE SIDE <br /> FORLDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE =fig <br /> ADDITIONAL COMMENTS: <br /> PHASE II _GRO.UT.vI-,NSPEC•TPON'' PHASE III FINAL INSPECTION <br /> INSPECTION BY ' 'OATE INSPECTION BY DATE o' <br /> CU T A11C n_.. 'I n Z7 <br />