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JAN JUAQUIN LULAL HLAL 111 U1J I K1L 1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, .CA 95205 Permit No. ,S <br /> Telephone: (209) 466-6781, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued //_ <br /> Thais Permit Ex ires . l Year From 'Date .'Issued <br /> x Complete In Triplicate <br /> i <br /> Application is hereby made to the San Joaquin Local• Health District for a permit to- construct <br /> and/or install the,iwork herein described. This .applicati-on is made in compliance with San <br /> U'oanui n County ordinance-14o. 1862 and the Rules and egu1ations of the San. Joaquin Local Health <br /> IDistrict. <br /> EXACT STREET ADDRESS' �/ C�/� L-2- C7 � <br /> f CITY/TOW <br /> Owner's Name / /�/ /44�'� Phone '7 . <br /> Address �/9 J--42- Z 72,,P tom - City <br /> Contractor's Name L t17�'1 License ���'horeq _VTa � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IINSURA*•SCCON FILE WITH SJLHD? YES <br />-TYPE--OF -WORKCheck <br /> { ) : --NEW-WELL-0V__ DE>=FEIN Elm �RECONDITIDN � - -DE5TRE1C1'ION�9�_--- <br /> WELL CWLORINATION Q WELL ABANDONMENT 0 ,: OTHER 0 <br /> PUMP INSTALLATION [a' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />�. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE _ TYPE OF WELL CONSTRUCTION' SPECIF TIS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _--i-7-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal vd ' <br /> Cathodic Protection _j,-'Rotary Type of Grout 7-�� , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b L <br /> PUMP INSTALLATION: Contractor 0.27-� 7-)9 L>J�P�" <br /> Type of Pump -. _ H.P. <br /> PUMP' REPLACEMENT: []State Work Done � <br /> PUMP REPAIR: ❑State Work Done j <br /> DESTRUCTION OF.-WELL:­ We11-Dikameter Approximate D'60th <br /> Describe Materia •an Procedure <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 /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. k <br /> SIGNED � TITLE: A DATE: /4 ) <br /> (DRAW PLOT PLRN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY DA E <br /> ADDITIONAL COMMENTS: ` <br /> PHAS ,II' G OUT INSPECTION P ASE III FINAK INSPECTION <br /> INSPECTION BY DATE_ 94-'28 INSPECTION BY DATE <br /> 13-2 <br /> i <br /> EH 1426 Rev. 12-77 d 1 P75Z err G <br />