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f <br /> SAN JOAQUIN LOCAL :HEALTH DISTRICT - <br /> J_EOR USE: 1601 E. Hazelton Ave. .;- Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6-- 2 5' <br /> 7 <br /> This Permit Expires 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 hereinidescribed. This application is made;i.n compliance with San <br />,'canu;n County erdinance',No. 1862 and the Rules and Regulations. of the. San Joaquin Local Health <br /> District. <br /> EXACTSTREET ADDRESS r �sS` / ! �,• CITY/TOWN'! T&c_ .17 <br /> �i''J'yiv <br /> Owner' s Name-y _ Cbd&t 511 s PhoneF -CU 63 <br /> Address <br /> Contractor's Name a, Li cense#,963-1 G / Phone ae3 <br /> s f <br /> IS CERTIFICATE OF WORKMAN`S CMPz<SATIO"1 INSURAMCE nN FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ _... <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER FJ a <br /> PUMP INSTALLATION [I PUMP REPAIR C3—" PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKA/e/vIl. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j. Cable Tool Dia. of Well Excavation S <br /> Domestic/private -Drilled , y -Dia, of=Well Casing W <br /> Domestic/public Driven Gauge of Casing _ <br /> ,o-- Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instaled b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: MState Work Done } <br /> PUMP REPAIR: OState Work Done <br /> _oe-c y_v_- - wl e IVA Tarr b.A.4 <br /> DESTRUCTION OF WELL: Well Diameter '" Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in ;accordance <br /> frith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin ,hocal <br /> iiealth 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 /> I WILL CALL Fgy,A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> iIGNED TITLE; ,",,., DATE: d" R3 Zr <br /> (DRAW PLOT PL N ON R EVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> IHA5E I ..r 4 F <br /> i '. <br /> kPPLICATION ACCEPTED' BY - - `y°° DATE S .2j <br /> ADDITIONAL-' COMMENTS : 3 -�- <br /> ­ . _ PHASE -II .GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY er/ DATE INSPECTION BY _ DATE <br />:H 1426 Rev. 12-77 1/-78 2M <br />