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w • <br /> JAN JUAgU IN LULAL. HhAL I H M I M I � <br /> ,.Q�QFFICE <br /> SE. 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No.-0/- <br /> ielephon' : (209) 466-6781 . <br /> APPLICATIOii FOR WELL. CON57RUCTION OR PUMP PERMIT Date Issued ,F A <br /> >' <br /> ThisPermit ires I Year From Date Issued. y �� � a <br /> omplete n r p cats ,~ <br /> Ypplication is hereby made 'to the San Joa°quin Local Health District for a permit to construct �'� 'jo�_ <br /> �Md,/or' install the'work herein -described. - =This application is made in compliance with .San <br /> 'aaquin County Ordinance.No. 1862 and the' Rules and Regulations of the. San Joaquin Local Health <br /> ),strict. <br /> CITY/TOWN <br /> EXACT STREET ADDRESS o� C1 ' v <br /> * , <br /> Dwner's Name Phane.7,�(� <br /> Address City , I <br /> Contrlictor`; Name License _ <br /> ?S CERTIFICATt' OF WOVIICIAJ S COMPENSATION INSURAINCE 0!I• FILE WITH SJLHD?' YES L==IQ " <br /> TYPE OF WORK (Check): NEW WELL, uE£PEN0 RECONDITION C3 DESTRUCTION❑ <br /> WELL CHLORINATION C3 WELL ABANDONMENT 0 OTHER p <br /> ..JMP INSTALLATION 0 -PUMP REPAIRC] PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: -SEPTIC TANK EWER LINES PIT PRIVY : <br /> SEWAGE DISP IELD CMM/SEEPAGE PIT OTHER <br /> "PROPERTY LINE - PRIOT WESTIC WELL PUBL ESTIC ' <br /> R <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> \� <br /> �� ustr a Cable Too Dia. of we xcavat on ; <br /> �mestitfprivate ---Drilled Dia. of Well Casing <br /> 'Domestic/public --- Driven Gauge of Casing <br /> Irrigation _Gravel Pack Depth of Grout ea O <br /> _Cathodic Protection �.� ary . Type of Grout <br /> Disposal Other Other Informat on <br /> =_ Geophysical Surface Seat Inst- e <br /> PUMP INSTALLATION: Contractor - 1AA <br /> Type of Pump —•— ;L <br /> POMP' REPLACEMENT: []State Work Done -. r <br /> PULP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Wel] Diameter Approximate Depth- .' <br /> Describe Mater a an Croce urs <br /> -- , <br />.I hereby certify that I have prepared this application. and that the work will be done in accordancii _ Y <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." y <br />'I WILL CALL FOR A GROUT INSPECTION PRIORITO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> Oh REV K <br /> FOR DE�W RENT USE ONLY <br /> PHASE I <br /> IQUnTMION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I PHASE III INAL INSPECTION f <br /> INSPECTION BY / DATE ? INSPECTION BY DATE !V,- J4-,,Jg_ <br /> 1/78 2M <br /> E}i 1426 Rey. 12-77 <br />