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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1� - <br /> OFF USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> i <br /> (Complete In Triplicate) <br /> Application is hereby made,�to the San Joaquin Local Health District for a permit to construct <br /> and/or i'nstall.the•work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET -ADDRESS 5- CITY/TOWNS XM-K) <br /> Owner's Name /yJ' � �y:•, oar N Phone '� �' .7 <br /> Address 6 17 ! S,RU P1,10, City �CICMN <br /> 'Contractor' s Name eG <br /> 10, <br /> i cense# ' . d2 Phone 442 <br /> 'IS CERTIFICATE OF WORKt1AN'S COliPENSATIO'N INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLE;jr- DEEPEN Q RECONDITION ❑^_ .-DESTRUCTION E] <br /> WELL, CHLORINATION 0 WELL ABANDONMENT 0 OTHER[3 <br /> �PUMP. INSTALLATION 0 PUMP REPAIR CI PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST:' SEPTI•C- kTANK ! SEWER NES S / PIT PRIVY <br /> SEWAGE DIS�O�TI=LDT � CESS�PO^OL/�5E PIT -�—� OTHERPROPERTY LINE"§gPRIVATE DOMESTIC WELPUBLIC DOMESTIC WELL-� ` <br /> INTENDED USE F. TYPE OF WELL CONSTRUCTION SPECIFICATIONS ti <br /> ndustri al _ .1- - ab-1-e-Tool Dia. of Well Excavation /0� L <br />' <br /> Domestic/private Drilled t Dia. , Well Casing <br /> Domestic/public Driven Gauge of Casing 2 s zffK Jplp <br /> k ' Irrigation f s , �� avel Pack Dep"th of Grout Seal <br /> Ca thod i c Pro�tec`t'i on -Pr` Mary Type of Grout 3 lJt <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Instal ed b wF ' <br /> _ Sid'LtJC-LG <br /> PUMP INSTALLATION. Contractor 0 U/R. <br /> Type.-of_Pump - H.P. f } <br /> PUMP REPLACEMENT,: State Work Done <br /> PUMP REPAIR,:,. []State Work Done <br /> DESTRUCTTON OF-;WELL: -4 Wel T' Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I Hereby certify that I have prepared this appl•i cati on and that the work:wi 11 .-be; done i n accordant <br />' -wit'h--San Joaquin County Ordinances , State Laws , and Rules and Regulations- of' t} e, San Joaquin Local <br /> H.Pa 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 /> ndt employ any person in such manner as to become subject to Workman' s Compensation <br /> -laws of California . " . <br /> "I.,WI'LL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED. ui = . � —. •-TITLE: DATE: <br /> (DRAW PLOT PLN ON REVERSE SIDE <br /> FOR-DEPARTMENT USE ONLY . <br /> PHASE 1 .,.� _. <br /> APPLICATION ACCEPTED B �r ATE q <br /> ADDITIONAL COMMENTS : _ <br /> PHASE II GROUT. INSPECTION 7PH AS II INAL ON <br /> ?NSPECTIQN BY ° DATE NSPECTION BY- <br /> L11 14 26 Rev. 9/78 �J l`7 2P1 <br />