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JAN JUAQUIN LUL AL: h1tA.L 1.h1 U1J I K14-I w� <br /> FOR OFFICE USE: /// 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No.-2g_��8/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued/�_i � <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate - <br /> Application is hereby made to the San Joaquin Local -. Health, District for a -permit' to construct <br /> and/or install the work herein described. This :appl.:ication -is made in- compliance with San .. <br /> L.oaq.uin County Ordinance -�o. 1862 and the .Rules and Regulations of the San Joaquin Local, Health _ <br /> District. <br /> EXACT STREET ADDRESS Wer 61DE' 6P��`�S'T�L� JUST- SourI4 CITY/TOWN <br /> Owner' s Name C—WVA12_1 Phone <br /> Address City.� � � <br /> Contractor' s Name <br /> L i ce n s eV-7= A Phone . 446-0,V6,S- <br /> TS <br /> _ <br /> TS CERTTFTCATE OF WORKMAN'S COMPENSATIO"I 1INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Ca DEEPEN 0 RECONDITION [] DESTRUCTION( � <br /> WELL CHLORINATION C] WELL ABANDONMENT� OTHER CI _ <br /> PUMP INSTALLATION C3 PUMP REPAIR E] PUMP REPLACEMENT Q <br /> DISTANCE 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well 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 <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter . � C. Approximate Depth 75 <br /> Describe Material and Procedure p;", ccatMh( p-o SO ;..�!c <br /> f W[vim ('QOu e_..�(.0 r oti 3 p;jr—_ Kc cCr C4 N <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <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 /> la of Cal 'fornia. " <br /> I WILL L FOA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. II <br /> SIGNED TITLE: 6CN DATE: to 11 717S <br /> DR W PLT L N ON REVERSE SIDE <br /> FOR PART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z 3/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY A J& DATE INSPECTION BY DATE - -1 <br /> H 1426Rev. 12T77 <br /> -1178 2M .. <br />