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* SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:: 1601 E. Hazelton Ave. ; Stockton,. CA 95205 Permit !+io': Zg_/_ _ I <br />_ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �. <br /> This Permit Ex fres 1 Year From Date Issued, <br /> Complete In Tri pl i cafe <br /> Application is hereby made to the San Joaquin Local health District, fo.r a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,oaquin County Lrdinance No.-"1862 and the� Rules and Regulations of,the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS J CITY/TOWN 4.c&M 2. <br /> Owner' s Name Mr. k1A X.Ldz aq Phone <br /> Address a6 7AA - Al, - 3—r- _ City �rhea_ --- <br /> Contractor' s 'Name <br /> -LI cense#3 �'l�3 Phone <br /> IS CE RTIFIC&:O'F WORKt1A�d'S CO"'1PENSATIOa�IEISURA"!C OPJ FILE 41ITHSJLHD? YES t w �d0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN-0 RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION C3' WELL ABANDONMENT Q OTHER F <br /> PUMP INSTAL.LATION.K PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK 1XV1 SEWER LINES PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL./SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE' DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> fINTENDED USE ­, TYPE -OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial Cable Tool. ' Dia, of Well Excavation <br /> �l Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i2 6;f1 - ' <br /> Irrigation f 6 ravel—Pack Depth of Grout Seal -i:v- <br /> Cathodic Protection Rotary Type of Grout dr AV 77-- <br /> Disposal Other ' Other Information <br />[ Geophysical `` = �_ Surface Seal Installed by: 1�-�� - - <br /> PUMP INSTALLATION: Contractor A/z11Z_Lt a! C, F tu44 -0/cdicic <br /> Type of :P:ump & H.P._/- !fes - <br /> .. <br /> PUMP REPLACEMENT: Q State Work Done = - `4 <br /> PUMP REPAIR: Q State Work-�Done <br /> r-DESTRUCTION- OF'"WELL.: WeVf' Di'amefer- - Approximate Deptff' <br /> fDescribe Materia and Procedure <br />� I hereby certify that I Have prepared this application and' that the work will be done in acco dance <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: y <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 /> I WILL CA L FOR A GR%q INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />' SIGNED TITLE: DATE: 9 I2=7� <br /> DR W PLOT PLAN ON REVER . SIDE Y <br /> FOR DEPARTMENT USE ONLY <br />, PHASE I 2 <br />;APPLICATION ACCEPTED BY DATE /a d0" <br /> ADDITIONAL COMMENTS: <br /> ' --PHASE—I I-GROUT INSPE71ON-- - -- -- PHASES II-�F4-NAL -INSPECTION . <br />,INSPECTION BY _ DATE - 6 , . INSPECTION BY , z DATE (f22'Z <br /> h <br /> EHA426 Rpv_ 19_77 1/782 . <br />