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A106 <br /> SAN <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH UISrR10 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No 2E/2.3:f <br /> Telephone: (.209) 466-6781 <br /> Date I55ued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - <br /> ' y�3 This Permit Ex i res,. 1 Year From ,Date Issued <br /> Complete In Triplicate <br /> Application is herebymadeto the San Joaquin Local Health . District for a permit toyconstruct <br /> and/or install the work herein described. This application is made in compliance with San <br /> . 'oanuJn County .Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS .3 �J CITY/TOWN <br /> Owner's Name Phone L", <br /> Address City <br /> Contractor's Name, Q LicenseV(2373 Phone�f <br /> IS CERTIFICATE OF-WORKMAN'S COMPENSATIO"! IEISURA"!CE ON FILE WITH SJLHD? YES I40 <br /> TYPE'OF WORK (Check) : NEW WELL Nr, , �, DEEPEN ❑ RECONDITION C3 DESTRUCTION <br /> WELD.C.H:L.O. RI.NATI.O.N_D—WELL-ABAND.ONhIENT❑.....,OTHER..( <br /> PUMP INSTALLATION DR� PUMP REPAIR❑ PUMP REPLACEMENT 0 � <br /> iDISTANCE TO NEAREST: SEPTIC TANK 1/S SEWER LINES i PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /.2o'CESSPOOL/SEEPAGE PIT OTHER <br /> —PROP-ERTY-1:I'NE.."="PRIVATE-DORIES TIC7WEf: PUBLIC-DOMESTIC WELL <br /> INTENDED`USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .Job <br /> Cable _Tool Dia. of Well Excavation E1 -D <br /> Domestic/private Drilled.- Did. of Well Casing <br />. --=Domestic/public: r Driven Gauge of Casing y <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l "A Rotary Type of Grout - } <br /> Disposal Other. Other Information <br /> Geophysical .__ -., Surface Seal Installed by;: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: _.._,. <br /> /__�_'Z.5tate Work Done a <br /> PUMP REPAIR: " 0_5iate''Work Done <br /> r�' �.T ' _DESTRUC7I.ON��OF °WELL":- -�Wel�l�-Diameter � - Approxi.mate� Depth <br /> Describe Material and Procedure w � <br /> T1 <br /> II 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 Joaqu3Q� 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 a6y person in such manner as to become subject to Workman's Compensation <br /> laws of Cal,ifornia. " <br /> I WILL CAL60R A GROUT INSPECTION nIOR TO GROUTING AND.4 FINAL INSPECTION. <br /> SIGNED % TITLE: DATE: <br /> W PLOT PL- _�N-ON REVERSE SI <br /> .FOR DEPARTMENT USE ONLYrz& <br /> PHASE I <br />'APPLICATION ACCEPTED BY G r DATE 7� <br />;ADDITIONAL COMMENTS: ;- <br /> P AS JI ROU .,INSPECTI PHASE 1-1 FINALIIWSPECTION <br />,INSPECTION BY,'" R .�i�.-DATE � INSPECTION BY DATE/-2-/7—$ U <br /> k <br /> well f7 57 <br /> .. <br />.EH 1426 ev_ 12-77 <br />