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SAN JOAQUIR -OCAL HEALTH DISTRICT .t <br /> FFICE USE: 1601 E. Hazelton Ave : Stockton, CA 95205 Permit No. �/v3 z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'PUMP PERMIT Date Issued 7 <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 fora permit to construct,' <br /> and/or install the work herein described. This application is made in compliance with S.an <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San'. Joaquin Local' 'Heaith <br /> District. <br /> EXACT STREET ADDRESS <br /> �.►� � . / CITY/TOWN <br /> o, �y <br /> ' C,���,�.. E� ..__. <br /> Owner's Name Z, 41 Phone�IAS 22 <br /> Address CQ City <br /> Contractor' s Name L1censejjj&�_. Phone <br /> IS CERTIFICATE"OF tdoRhIAN'.S CQ!IPENC-ATION ISS fIRANCE ON FILE WITH SJLHD? YES Ido �I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN Q -_1J RECONDITION.❑ � DESTRUCTION(� <br /> WELL CHLORINATION a WELL—ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANS T SEWER LINES �4 PIT PRIVY <br /> SEWAGE DISPOSALS FIEL iCESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINVA,tPRIVATTEEEDDOMESTIC WELL— PUBLIC DOMESTIC WELL 27 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 .Excavation <br /> AIFx <br /> _Domestic/private Drilled Dia. of Well 'Casing - 11 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea r 1 <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical , Surface Seal installed b : x <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> p /'; <br /> UMP REPLACEMENT: .[] State Work Dane - <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe,Material and Procedure <br /> I hereby certify that I have prepared,this application -and that the work will be done in accUrlance <br /> with San Joaquin County Ordinances , State•Laws ; and�'Rules and Regulations of the San Joaquin Lo c`a1 <br /> Heal-th 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 Cal i forni-a-" <br /> I WILL CALL FOR GROUT NS QCT PRIOR TO GROUTING'AND A FINAL INSPECTION. <br /> SIGNS TITLE: DATE: / r. <br /> DRAW PL T PLTN <br /> ON REVS S SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICAT°ION ACCEPTED BY _ DATE //,,/ <br /> ADDITIONAL COMMENTS: V __ __—_—..._�._� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY VDATE <br /> EH 1426 Rpv_ 12.77 1 17SI 9M <br />