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m JOAQUIN .LOCAL ,HEALTH DISTRICT �_ <br /> FOR F CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Nod. <br /> .. Telephone: (209) 466,--6781 <br /> APPLICATION FO1.R WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This, Permit Exp ices 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the- San Joaquin Local Health <br /> District. <br /> EXACT 'STREET ADDRESS /O. L4 ` 5'i7�� �s CITY/TOWN <br /> Owner's Name A,- o d 7. i Phone <br /> Address C ? City v <br /> Contractor' s Name ' z <br /> License# /p?7ij-'—Phone 6Y 4 <br /> IS CERTIFICATE OF WORKMAN'S C011,11FUNSATIOIN IINSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN Q 'RECONDITION DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER{:. <br /> PUMP INSTALLATION CI PUMP REPAIR[Z PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT PRIVY a" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �(1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool: Dia. of Well Excavation <br /> i Domestic/priva.te Drilled Dia. of Well Casing <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 c� �/� .. - •YF . <br /> k Type of 'Pump H.P. -A-4�" <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: (,State Work Done �cae� <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Ddscribe `Material and Procedure <br /> I hereby certify that I have prepared this .application and that the work will be done in accordanc( <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 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 /> I laws of California." <br /> 1 I WILL CALL FOR A GROUT IN ETI P-R TO GROUTING ANDA FINAL INSPECTION. <br /> i SIGNEITLE: �rrl' DATE: <br /> D LOT PDAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE, ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z,16_Z7�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I F)NAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY' DATE, _1, 1� el7yl <br /> i <br /> -Pu ,agF Mau 19-77 -1178 2M <br />