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v t SAN JOAQUIN°LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton- Ave„* Stoc-kton, CA 95205 Permit No, EOR O <br /> . } <br /> Z Telephone: (?09) 466-6781 �Z� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expire-s-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 i s made in compliance with -San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the,San Joaquin Local Healt <br /> District. <br /> -1414 - <br /> EXACT STREET ADDRESS 3� ?l Al. FAN E' RP • CITY/TOWN ����j <br /> Owner's Name CRI-VIS 66IV',f7 v- ti Phone { <br /> Address ' �., / 0 t � TCac+� - City Snck---rm) <br /> Contractor' s Name LL /1dOLi cense# 0'-,Phone Kq7- 4�� <br /> IS CERTIFICATE OF WORKiiAN'S C01,1PENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN [I RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST: SEPTIC -TANK /T56 SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT -tTHER <br /> f PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/privateDrilled Dia. of Well Casing. +"t/ <br /> Domestic/public Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection ERotary Type of Grout <br /> Disposal Other Other; Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material anE Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance!.. <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 /> laws of California. " <br /> I WILL CALL F A GR96T IN PECTIO PRIOR TO GROUTING AND A FINAL INSPECTION. 7� <br /> SIGNED TITLE: DATE: "` ) ` <br /> (DRAW PLT PLAN ON _REVERSE SIDE <br /> FOR D PARTMENT,USE- ONLY y <br />'I <br />` PHASE I Ole- <br /> APPLICATION <br /> ldAPPLICATION ACCEPTED BY t:_X/1� �� DATE r - 25 <br /> ADDITIONAL COMMENTS: 6e4 arC4402-R, <br /> PHASE II GROUT IN5PECTION PHASErnI FINAL IffSPECTI N <br /> INSPECTION BY 4M.OATE7 -)L INSPECTION BY AkOATE -7 ),zJ7 <br />' cu Inns n,... 10 "7 1/7$ 2.M <br />