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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FFICE 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//,22-,7,K <br /> This Permit Expires 1 Year From Date Issued <br /> i <br /> ' Complete In Triplicate <br />' Application is hereby made to the San <br /> a Joaquin Local Health District for permit to construct <br /> q ® <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,oaa,,:in County Ordinance 1�o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr4ct. <br /> EXACT STREET ADDRESS 2-627, CITY/TOWN o,4i6-A4C* �ti <br /> Owner' s Name ,� .T"/ /-� Phone-- -! --' 3 el-S2 <br /> Address <br /> City <br />;Contractor' s Name 1�� P 4., 4,vd LicenseaWOZ Phone <br /> IS CERTIFICATE �, �, <br /> C E OF WORKMAN'S C0�1PENSATIO�i I�ISURA��CE ON FILE WITH SJLHD? YES �;; NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ® RECONDITION ® DESTRUCTION Cj <br /> WELL CHLORINATION WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION 'S PUMP REPAIR® PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK rJ SEWER LINES/�Z. � PIT PRIVY <br /> SEWAGE DISPOSAL FIELDESC SPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialable Tool Dia. of Well Excavation /22 <br /> Domestic/private Drilled Dia. of Well Casing 9 <br /> Domestic/public Driven - Gauge of Casing r: _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout / <br /> Disposal Other Other Informatioff <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 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 /> la 's California. " 4` <br /> 1 WILL LL OR A GROUT NS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ; <br /> TITLE: DATE:--//—/ G� <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE " .2 -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �' lC., DATE /—�� INSPECTION BYj��,�� DA7;E <br />_H - 1 /78 2M <br />