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FFICE FFI S JOAQUIN LOCAL HEALTH DISTRICT <br /> USE 1601 E lazelton Ave. , Stockton, CA 9. 5 Permit No. l/- Z, <br /> ``Telephone: (209) 46676781 , ;:. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date-Issued - <br /> (Complete In Triplicate) ; <br /> Application is hereby made to the San Joaquin Local Healt•h '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 k " s <br /> 7161. So. Este on IIe llvt a Rc . CITY/TOWN/V Es0e l <br /> Owner's Name_. F. Ha renPhone '.38-35,12 <br /> Address Y <br /> 'ty :KHSC .lon <br /> Contractor's NameX , _ <br /> _ s'on Drill n Li ten e�26-�!J ne --%67-1060' <br /> IS CERTIFICATE OF ORKPIAP�'S CO'iPENSATIOPd INSURA'.'C ON FILE WITH SJLHD? YES <br /> TYPE'OF'-WDRK -Chet ) -NEW`W�LL DEEPEN Q � iRECONflITI{�N` � - r- ' <br /> Q DESTRUCTION[�.��"..- <br /> .WELL CHL RINATION 0 WELL ABANDONMENT Q OTHER� <br /> -_ �-- PUMP INSTALLATION ❑ PUMP REPAIR 0— RUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC .TAN SEWER LI,NES ;'O,Cffix PIT PRIVY <br /> SEWAGE DISPOSAL FIELD s--jCESSP OL/SEEPA EPIS`---OTHER' <br /> PROPERTY LIN PRIVATE DOMESTIC WELL' -PUBLIC D MESTIC WELL— cd <br /> p INTENDED .USE' - TYPE OF-WELL_. <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Wel Excavation d — <br /> Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/pub!1ic Driven Gauge of Casing A E <br /> I rri i _ =- <br />---= --�.. � Gravel Pack Depth of Grout Sea e <br />.� a hadic Protection _Rotary . Type of Grout <br /> ' Disposal s <br /> Other Other Information ` <br /> eophysical _ Surface Seal Instaled <br /> PUMP INSTALLATION: x 1 Contractor-. <br /> y Type of1pump' t <br /> PUMP RE`PL-ACEMENT: H. <br /> ' ❑State Work Done f <br /> PUMP REPAIR: ❑State Work Done <br /> =, . <br />�E,STRUCt1 N= OF WEUL=' <br /> Alyprokiman Depth-' <br /> Describe Material and Procedure <br />[ hereby certify that I have prepared this application and that the work will be done in accordance- <br /> 0th San Joaquin County Ordinances, State Laws , and Rules -and Regulations of the San Joaquin Local <br /> iealth District. Home owner or 11-tensed 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 /> WILLbCALL FORA GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. : . <br /> IGNED <br /> DR PLOT L N TIT : _sae DATE: <br /> RE _ 5',8 q �%%' <br /> VERSE SIDE <br /> RTMEN USE ONLY T <br /> RASE I F R P r ,�3� ,. - <br /> PPLICATION ACCEPTED BYE' <br /> DDITIONAL COMMENTS:: ' DATE <br /> PHASE I. GROUT N PECTIO - <br /> ISPECTION BPHASE IIIURAL SPECTION +� <br /> Y ; <br /> DATE 8Y DAT <br /> i 142 )Rev. 9/78 INSPECTION <br />