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a <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. r- Stockton, CA 95205 Permit No. &'- y <br /> Telephone (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date issued <br /> This Permit Expires 1. Year From Date Issued <br /> Complete In Triplicate:. <br /> Application is hereby made to the San Joaquin Local' Hea,lth, Distr.ict for a permit to construct 5 <br /> and/or install the work herein described. : This application is made in compliance with San F <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin- Local Health <br /> District. j <br /> EXACT STREET ADDRESS_y CITY/TOWN <br /> Owner's NamePhoney__E=_L 2.3 <br /> Address Id'lid <br /> City �! <br /> Contractor's Name LicenseiMI� Z Phonek-�12- „7�/p ' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IN5 RA*LCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION 0._ "'WELL ABANDONMENT O OTHER 0 j <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTEJ <br /> DISTANCE To! <br /> NEAREST: SEPTIC TAN SEWER LINES -- PIT PRIVY --- <br /> SEWAGE DI SPP SAL F1 ---CESSPOOL/SEEP GE PIT OTHER <br /> PROPERTY LIN&+PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indu''strial Cable Tool • Dia. of Well Excavation �r <br /> ® 40 <br /> Domestic/private Drilled Dia. of Well Casing Zo <br /> Domestic/public Driven - Gauge -of Casing Zo <br /> Irrigation Gravel Pack Depth16f Grout Seal UvR= <br /> Cathbdic Protection Rotary Type-of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done } <br /> PUMP REPAIRED O State Work Done <br /> i <br /> DESTRUCTION, OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> n s <br /> I hereby certify that I have prepared this applicat ion and that the work. wiI be done in accordance' <br /> with San `Joaquin County Ordinances , State Laws, and -Rules and-Regu'1-ations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature. certifies the following: <br /> "I certify that in the�,performdnce of` the work.- for which this permit is issued, I shall i <br /> not employ any person in such. manner as to become subject to Workman's Compensation <br /> laws of' Ca_lifornia. 1'. � • 1. . <br /> I WILL C FOR A OUT IN E ON OR TO GROUTING AND A FINAL INSPECTION. <br /> i <br /> SIGNED TITLE: - DATE: t ? <br /> W P T L ON REVERSE IDE <br /> OR DEPARTMENT USE ONLY I <br /> PHASE I ....„ .,_. _ <br /> RPPLIC TI0 ! ACCEPTED DATE 5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZW---- DATE <br /> 1EH._1426' kev... 12-.77 C' �' 7A 2m <br />