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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> TF <br /> CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95265 Permit No.Z$j 3 a J <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 9--,c->g' <br /> This Permit Expires 1- Year .From Date Issued <br /> Complete Iri 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 San " <br />.'oaouinn County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> / l <br /> EXACT STREET ADDRESS ME e15 �a s CITY/TOWN <br /> Owner' s Name Phone <br /> Addressl r' r � ;V, L . Ci ty <br /> Contractor's Name e _iE�rA, License#Ll --Phone_ --'767� <br /> IS CERTIFICATE OF WORKMAN'S CnM NSATIO,f INSURANCE ON,FILE WITH SJLHD? YES. NO <br /> TYPE OF WORK. (Check) : NEW WELL 0 DEEPEN ❑,. RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERF-3 <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT,[ <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 /> crpomestic/private Drilled Dia. of Well CasinCM <br /> g <br /> Domestic/public Driven - - " ..Gauge of Casing <br /> Irrigation , Gravel Pack Depth of Grout Seal <br /> ,. . Cathodic Protection Rotary Type of Grout <br /> Disposal "" Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor rp <br /> rx <br /> Type of Pump H.7 <br /> PUMP REPLACEMENT: State Work Done J 42v , ► , <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION't,OF WELL: Well Diameter Approximate Depth .' <br /> Describe Material an2 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 /> iealth District. Homeowner or licensed - agent's signature certifies the following: <br /> fI 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 />[ WILL CALL FOR A GROUT INSPE 0 PRI GROUTING AND FINAL INSPECTION. <br /> iIGNED <br /> TLE: DATE: ,,rr <br /> DRAW PLOT PL ON REVERSE SIDE <br />'HAS E I FOR DEPARTMENT USE ONLY 1 <br /> IPPtICATION ACCEPTED BY 11t,A DATE <br /> IDDITIONAL COMMENTS: <br /> PHASE IIlGROUT: INSPECTION PHASE III FINAL INSPECTI N <br /> NSPECTION BY DATE INSPECTION BY DATA ( <br /> H, 1421; RAU 19-77 .. "'� - y- ., 1"n nor <br />