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a .. <br /> SAN` JO'AQUIN LOCAL HEALTH DISTRICT <br /> 7FOR FFICE USE: 1601_ E.' Hazelton Ave. , Stockton, CA 95205 Permit No. 7f-SCS <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued//,7/` <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate C�f3 _ 2�o�ys <br /> Application is hereby made to .the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereih1described. This application is made . in compliance with .San <br /> Loan+,yin County Ordinance No. 1862..and the Rules and Regulations of the San Joaquin Local .Health ' <br /> District. ?fiil <br /> EXACT STREET ADDRESS �. -� . . �or�. �. CITY/TOWN ci-To ! <br /> Owner's Name �.rJw 1,n,3I i ,� v Phone 2 t 8 <br /> Address33 1 City smc�7 _— <br /> Contractor's Name �,.� Qj, „�F ._ License#2 0 ' Phone <oCo'L I � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATiO"1 INSURANCE ON FILE V1IT.H SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ ' DESTRUC 1.0* <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑. . PUMP REPLAC <br /> e <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE IIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS u <br /> Industrial I Cable Tool Dia. of Well Excavation v <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven 3, . Gauge of Casing 1 `+ <br /> Irrigation Gravel Pack Depth of Grout Seal_ <br /> Cathodic Protection Rotary Type of Grout L <br /> Disposal Other Other Information /;Zbzi W„#,. ce)7n , . <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump H. . <br /> PUMP' .REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done I <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 /> 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 FO A GROUT NSPECT 1RI0.RJTrO GROUTING AND A FINAL INSPECTION. <br /> SIG D TITLE: DATE: <br /> DRA OT PL N ON REVERSE/SIDE) r <br /> L-IFOR DEPARTMENT USE ONLY <br /> PHASE I �p DATE �79 <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION " <br /> INSPECTION BY DATE INSPECTION SY' ,4&14X K&Z46ATE rp Ti <br /> ru i a9A nn” A 1_77 `. 178 <br />