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SAN JOAQUIN LOCAL„;HEALTH. DISTRICT <br /> FFICE USE: 1601 E. Hazelton ton Ave. .' <br /> Stockton, CA 95205 Permit No.'7,5P- <br /> Telephone: may°° <br /> (209)' 466-678I' <br /> ADate Issued /-3-PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ;1y <br /> This Permit Expires I .Year. Fram. Date Issued <br /> Complete In Triplicate <br /> Applicationfis hereby made to the San Joaquin Local Health Distric �f <br /> t or. a permit to construct <br /> and/or insta the work herein described. This application is made in compliance with San <br /> ._oaquin County 'Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local. Health <br /> District. <br /> EXACT STREET ADDRESS RIs Rd, M, rhe s Yare,_,'yVy 1?e CITY/TOWN L� <br /> Owner' s Name r <br /> Address Phone-, 7Z <br /> �, 5'�, <br /> City ' <br /> Contractor' s Name License# 6 -Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO`! INSURANC ON FILE WITH SJLHD? YES 1140 p <br /> TYPEOF�WORK (Check) : NEW WELL CI DEEPEN 0 RECONDITION Q DESTRUCTION[0 <br /> WELL CHLORINATION E] WELL ABANDONMENT O OTHER] <br /> PUMP INSTALLATION M- PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK VM (SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E <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 .t Drilled Dia. of .Well Casing <br /> Domestic/public-. Driven Gauge' of Casing , <br /> rrigation -- Gravel Pack _ Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: ContractorU,e � ,( <br /> Type of Pump_ 1 ,.h rsG,£___.. H. •-- _ <br />)UMP_ REPLACEMENT: �]State Work Dane <br />)UMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: —Well Diameter` <br /> Approximate Depth <br /> Describe Material and Procedure ; <br /> a <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> lith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth 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 California. <br /> WILL CALL FOR A GROUT INSPECTION,,PRIOR TO GROUTING AND A FINAL INSPECTION. 3 <br /> IGNED '' <br /> �ONRE�RSE <br /> �es ��,�. DATE:DR W PLOT PL N SIDE <br /> Ile <br /> HASE I <br /> FOR DEPARTMENT. 0 ONLY <br /> PPL. � - <br /> ICATION ACCEPTED BY <br /> DATE 7 <br /> DDITIONAL COMMENTS: �: zy� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION 1 <br /> VSPECTION BY DATE t INSPECTION BY <br /> _ �� � � DATE 3//7h)_ <br /> 1 1426 Rev.- .12=77 - , <br />