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---�. SAN JOAQQIN LOCAL; HEALTH DISTRICT <br /> �Q@�QFf E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �7- Sy'� <br /> " Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S -� <br /> This Permit Expires 1 Year From Date Issued I <br /> Complete In Triplicate 4 = <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 application is made in compliance with San <br />%'oanuin County Ordinance "�o. 1862 and: the Rules and Regulations of the San Joaquin Local Health <br /> EXACT' STREET ADDRESS C a(L& -C,. 04V- LOT 5� CITY/TOWN <br /> Owner's Name zV 6 0 kj�VPhone <br />.Address � - . C, -S � � <br /> Contractor's Name A [,� [ ,.� erS License#3 Phone9 - �� <br /> IS CERTIFICATE' OF 11 WORKMArVS 4MPENSATION TINSURA"ICE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW- WELL 0 DEEPEN ❑ PRECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WE•LLABANDONMENT ❑ OTHER (. <br /> PUMP INSTALLATION ❑ PUMP •-REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK_j<)3 SEWER LINES /0-6 "'P-IT-PRI-VY <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 /> Domes ti c/publ i c ' - " - �Driven Gauge of Casing 16 6 - <br /> Irrigation Gravel Pack Depth of Grout Seal - r , <br /> Cathodic, Protection Rotary Type of Grout w, <br /> Disposal' Other Other Information <br /> Geophysical Surface Seal 'Installed by: <_;.j p GJ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.p, <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State. Work Done <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth <br /> i <br /> • Describe Materia and 'Proce ure <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 th,e following: <br /> "I certify that in the performance of the work for whi-ch 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 Ca1•1-forni'a�-'—_. .� �. --_.. ,,,. - ��,� _� �� _ r- _ �... <br /> I WILL CALL FOR A GROUT INSPECT40N PRIOR TO GROUTING-AND A FINAL INSPECTION. <br /> SIGNED +.� TITLE: �' DATE: Z-9 <br /> (DRAW PL T PL N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED DATE S"' 7 <br /> ADDITIONAL COMMENTS: " <br /> PHASE II ROUT INSPECTION PHASE III FJNAL INSPECTION <br />[NSPECTION BY DATE - $- tel INSPECTION BY DATE , <br /> 4 <br />=H 1426 Rav_ 7-9-77 1 I-7R ?m } <br />