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r ' SAN JOAQUIN LOCAL, HEALIH UIS[RIL:I + <br /> FOR OFFICE USE: 1601 E._-Hazelton Ave. , Stockton, CA 95205 Permit No.7_7-4/5�� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION..OR. PUMP PERMIT Date Issued-6—/o--22 <br /> This Permit Ex i.res 1 Year From .Date Issued <br /> Complete In Triplicate <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 /> k-oaquin County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS S' CITY/TOWN <br /> Owner's Name Phone$ �`�7 ' <br /> Address c977 , 3 So City a:&� <br /> Contractor' s Name License# Phone ' <br /> ; S CERTTFICATE OF WORKtIAN'S 'CO"lT'ENSATIM INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ I DESTRUCTION❑ g.3 <br /> WELL CHLORINATION © WELL ABANDONMENT'` OTHER 0 ..J <br /> PUMP INSTALLATION Dq PUMP REPAIR❑ rP11MP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PIT�EPRI`VY �� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PU.BLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC T"FI.Ca-TIONS -� <br /> Industrial Cable Tool Dia. of tielj—Excavation <br /> Domestic/privat <br /> xcavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Gro6t <br /> Disposal Other Other Information CE <br /> Geophysical - c Suiae5ea1.. Installed b 4 <br />-PUMP INSTALLATION: Contractor 4 <br /> Type of Pump ,, z - H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑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 accordana <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_wo.r-_k far which this p <br /> 7 o an - peYrmi t i s ss_ue_d.,.,�..I_s.hal 1 <br /> not em � <br /> P y. y person in such manner as to become subi:ect to Workman 's Compensation <br /> laws of California. " <br /> I WILL CA GR UT NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: <br /> DATE:s� �7 -�� <br /> DR W PL T PLTN ON REVERSE SIDE t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEA/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION V ! <br />[NSPECTION BY DATE INSPECTION BY ATE <br />-H-'1426 - Rev. 12-77 _ 4_._. _ ,. 17A 7M <br />