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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.96- q6O <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT " Date Issued �—�q <br /> This. P.ermit Expires 1 Year From Date Issued <br /> . Complete In Triplicate p <br /> , Application is hereby made to the San Joaquin Local Health District for a permit to onstruct <br /> ' and/or install the work herein described. This application is. made in compliance with San <br /> * .'oacluin County Ordinance No.- 1862 and the Rules and Regulations of the San Joaquin ocal Health <br /> ,District. ' <br /> EXACT STREET ADDRESS t a.l �tclo 1 � CITY/TOWN 4, <br /> Owner' s Name s- Phone <br /> Address �Z.2 1 _ ..__ City aGle y <br /> Contractor's License# /y'37-xj---Plione -3- 7G ..--g' <br /> t IS CERTIFICATE OF WORKMAN'S M ENSATIO'N IPJSURAI�CE Oft FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN [1 RECONDITION [] DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT_ p OTHER 0 �- <br /> PUMP INSTALLATION .[ PUMP REPAIRW, PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable: Tool �`�3 Dia. of. Wel l Excavation <br /> Domestic/private, , _ Drilled Dia. of Well Casing <br /> Domestic/public h Driven Gauge of Casing <br /> �C Irrigati-on•, vV Gravel Pack Depth of Grout Sea <br /> Cathodic Protection «; _ = . Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical, Surface Seal hnstalled by <br /> , PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i50 <br /> PUMP REPLACEMENT: State Work-Done �� ,✓ ,._ / ��-� ,��, 4614 <br /> t PUMP REPAIR: State Work Done �^, �, �,=Z �..0yC T <br /> ; DESTRUCTION. OF WELL: Well Diameter Approximate Depth <br /> 1 Describe Material an2 Procedure <br /> , I hereby certify that I have prepared this application and that the work will be done in accordant <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 "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 Cal.ifornia." <br /> j. 1 WILL CALL .FOR- A GROUT INSPECTIO R GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: DATE: <br /> dR�&IPL�OTP*LOUM REVERSE SIDE { <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> yAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL 'COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> . INSPECTION BY DATE INSPECTION BY f' DAT f <br /> IF'H 1a91; Dnv '19_77 1 /7R 2M <br />