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"----+ Jail UUAgUlIY LULhL IILAL 1 Il Ulm t i�11,i <br />.FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7'?-,5,5 <br /> Telephone: .0-09), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�,5-3/- <br /> (Complete In Triplicate) <br /> application 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 />,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Aistrict. <br />.XACT STREET ADDRESS /J` CITY/TOWN �c <br /> Dwner's Name Phone <br /> Kddress4 Akin; <br /> AE i 3n City e-4f Q <br />'ontractor's Name License# -?LPhone 7 H <br /> S CERTIFICATE OF WORKMAN'S CTUXATTON INSURANCE ON FILE WITH SJLHD? YES, _ NO � <br /> YPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER Q <br /> PUMP INSTALLATION R PUMP REPAIR❑ PUMP REPLACEMENT ( <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F ELD CESS /SEEPAGE PTT— OTHER <br /> PROPERTY LINE - PRIVA E D ESTIC WELL PUBLIC WESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br />�rCathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br />.JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />,JMP REPLACEMENT: []State Work Done <br /> Mme? (2State .Work:Done Mp�a _ �,_ j4,) <br />�STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> Nth San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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 CAL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> G N E D TLE: DATE: <br /> 4,fgRAW_ PLOT PLM ON REVERSESIDE) <br /> DEPARTMENTFOR SE ONLY <br /> WASE I <br /> P—Li—CAYiON ACCEPTED BY �Zj r DATE <br />■DITIONAL COMMENTS: <br /> PHASE II r1bOU NSPECTION PHASE III FINAL INSPECTION <br />■SPECTION BY DATE INSPECTION BY DATE /OIS177 <br /> 14 26 Rev. 9/78 X9/78 M <br />