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5AN JUAQU1N LUUA.CH1AL1h U151KiL1 t <br /> FFICE USE: 1601 E. Hazelton Ave.,, Stockton, CA 95205 Permit No. <br /> _ Telephone: (209), 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires-1 Year From Date Issued <br /> Complete In ,Tripl i,cate <br /> : Application is hereby made to the San Joaquin Local, Health District for a permit to:construct <br /> sand/or install the work herein described. This ..application is made in compliance with San <br /> ' ,oaquin County Ordinance 1,50.:11862 and the Rules and Regulations of. the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS � .5~ fi(J�! EXACT <br /> Owner's Name P h o n e �a <br /> k _ <br /> Address '7� - GCJ� # City <br /> Contractor' s Na e r <br /> �Licen��d29 Phone-7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIONINSURANCE ON FILE WITFI SJLHD? YES t10 <br /> TYPE OF WORK (Check).: NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> t: <br /> DISTANCE TO NEAREST: SEPTI.'C TANK SEWER LINES PIT PRIVY <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 V' <br /> Domestic/private Drilled Dia. of Well Casing LIS <br /> Domestic/public Driven Gauge of Casing <br /> c�frrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 4ther Other InformationGeophysical Sur ce Seal installed b :PUMP INSTALLATION: Contract ryJ [/Type of mF H.P. / <br /> F <br /> PUMP-REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: WelllDiameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby certify that I have prepared this application and that the work will be done in accordar <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations 'of the San Joaquin Locz <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 alifornia. " I <br /> I WILL CAL �OR A RUT IN E ION , /RIOR TO GROUTING`'AND INA INSPECTION. <br /> SIGNED TITLE: f' Com, DATE: <br /> f-PAAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE I I <br /> .APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS:. <br /> 4 PHASE II GROUT� INSPECTION PHASE III FINAL INSPE TION J Z� <br /> INSPECTION BY DATE INSPECTION BY Gay%. DATE, Z <br /> n_ � '771/78 <br /> v � 2r <br />