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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> x: r'FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 , Permit No.�gj// $"_ <br /> Telephone:, (209) 466--6781 :_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued s <br /> This Permit Ex, ices 1 Year From Date Issued h, <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 '11862 and the Rules and Regulations -of the San Joaquin Local Health <br /> District. <br /> EXACT STREET. ADDRESS 0 �CIA1 �' �, CITY/TOWN <br /> I-Owner' s Name Phone <br /> od <br /> Address. (� City !! . <br /> License 'hone <br /> Contractor' s Name 4L.. ._ . -_ <br /> IS CERTIFICATE OF WORKMAN" COMPENSATIONINSURANCE ON FILE WITH SJLHD? YE NO <br /> TYPE OF WORK (Check) : NEW WELVK DEEPEN ❑ PRECONDITION DESTRUCTIONO <br /> WELL CHLORINATION p WELL ABANDONMENT C1 OTHER 0 _- Q <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT Ca <br /> DISTANCE TO NEAREST: SEPTIC TAN RI_52C-'SEWER LINES_A:?_?�PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S PGE PIT_�/�frTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial D'i a of.'Well Excavation <br /> �Domestic/private �Dri 11 ed Qi a. of Well "'Casing I <br /> Domestic/public Driven Gauge of Casing 42 ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal -= Other ��„ Other Information <br /> Geophysical- TM ._ Sarface Seal Installed -by: <br /> PUMP INSTALLATION: Contractor ri <br /> Type of Pump _ - w - H.P. f <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> F <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 sub ' ct to Workman 's Compensation <br /> laws of Califor ia." <br /> I WILL CAL F A OUT PECTION PRIOR TO GROUTING FyNAL INSPECTION. a / <br /> SIGNED <br /> 0VVV_ERR"!SE <br /> DR W,PLOT L NaON SIDE <br /> FOR DEPARTMENT 'U E ONLY <br /> PHASE I '� "� ` <br /> APPLICATION ACCEPTED BY DATE a g�74- <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .K DATE -3 <br /> ru 1-AI)� oma,. '11_77 1J 78 2M <br />