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r <br /> JAN JUAQU1N LULAL MALIN U1JIK11.1 <br /> FOR FFICE USE: 1601 E. :elton Ave. , Stockton, CA 95, Permit No. 4// <br /> Telephone: ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP :PERMIT Date Issued S' I- <br /> This Permit Expires 1 Year From Date Issued <br /> Comp ete . In Triplicate). <br />,oplication is 'hereby made to the San. Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This, appTication is made-.in compliance with San <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />,;strict. _ 3s— + <br /> XACT STREET ADDRESS �2 00 LJ., CITY/TOWN v <br /> Iwner' s Name 9.. .� <br /> PhoneR ��- 66 c 2=1 "\ <br />,ddress_ City , <br />:ontractor' s Name � �c. 'C'< • License�3oig'a-r PhoneP3:i 10�3 �- 7 <br /> S CERTTFICATE OF JORKIIAN'S COMPENSATION INSURA"ICE ON FILE WITH SJLHD? YES ✓ NO <br /> YPE OF WORK (Check) : NEW WELL,U DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ n <br /> IISTANCE TO NEAREST: SEPTIC 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 4 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cdble, Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Uri4en Gauge of Casing <br /> Irrigation Grhvel Pack r Depth of Grout Sea <br /> Cathodic Protection Rdtary 'Type of Grout <br /> Disposal ' 7—other; Other Information-- <br /> Geophysical Surface Seal Installed by: <br /> UMP INSTALLATION: Contractor i10L i ' ��: -�- H CI <br /> Type of. Pump 1 <br />-UMP REPLACEMENT: []State Work Done <br /> HUMP REPAIR: ❑State Work Done <br />■ESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Materia an —Procedure <br /> hereby certify that I have-( prepared this. applicotion and that the work will be done in accordanc. <br /> ith San Joaquin County Ordinances , State Laws , and Rules and .Regulations of the San Joaquin Local <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 ths ,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 CA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> El :TITLE: SEIDE <br /> DATE:Y_2�(-7� <br /> RAW LOT L N ON REVE S <br /> FOR DEPARTMENT USE ONLY <br /> MASE I <br /> 'PLICATION ACCEPTED BY DATE, <br />-)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY / v -DAT 7 <br /> 1nner n_.. •n -r-. <br /> C01 /7R W <br />