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SAN JUA4UIN LUUAL HLNLIM UISIKILI <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No ZB is�9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -, <br /> This Permit Ex fires 1 Year From Date Issued <br /> Complete In Triplicate <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San <br /> 'aquin Count Ordinance No. 1862 and the Rules and Regulations of he San Joaquin Local Health <br /> strict. y ^�a� ��� Cs ta0Qp—. ; s.5 �"2 � � <br /> P eck - Z✓ —% / <br /> Z. <br /> et C)OU <br /> XACT STREET ADDRESS CITY r <br /> �ner' s Name 5o G R wo Vroor Phone 8t,7 <br /> ddress d -u City �hN 4 CIV <br /> �ntractor' s Name © W N License# Phone <br /> S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> lqPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION Q DESTRUCTION❑ � <br /> WELL CHLORINATION O WELL ABANDONMENT 0 OTHER 0 t <br /> PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT O <br /> STANCE TO NEAREST: SEPTIC TANK 0 b SEWER LINES v PIT PRIVY N IC <br /> SEWAGE DISPOS�FIELD ' R {6ES�SPOOL/ EEEPP GE PIT q•40THER�E <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIgNS <br /> Industrialy Cab a TO Dia. of We11 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information is <br /> Geophysical Surface Seal Instaed by: 0 <br /> MP INSTALLATION: Contractor Q� <br /> Type of Pump <br /> UMP REPLACEMENT: State Work Done <br /> MP REPAIR: O State Work Done <br /> STRUCTION OF WELL: Well Diameter N'Q h -R Approximate Depth <br /> Describe Material and Procedure <br /> ' hereby certify that I have prepared this application and that the work will be done in accordant <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <br /> �alth 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 /> WILL CALL R T SPECTION PR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: DGCJ '% DATE: VV),K-- <br /> OT PLAN <br /> ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> HASE I <br /> PL TION ACCEPTED BY DATE <br /> � CDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1;1 FINAL INSPECTION <br /> ECT ON BY DATE INSPECTION DATE !'f�b� <br /> 1/78 2U <br />