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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE 1601 E. Hazelton Ave. , Stockton, CA 95205- Permit No.14 1 Al a I/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex i'res 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 is made in compliance.-with San <br /> Joaquin County Ordinance No. 1862 and ,the Rules and Regulations of the San Joaquin Local' Health . <br /> District. <br /> EXACT STREET ADDRESS 2 d -! m- 33 CITY/TOWN _ <br /> Owner's Name TQ`Vr r Phone <br /> Address 2231 afL, �Y-rg ls�oj�aw City nac <br /> Contractor's Nameaan&j, � ,p � �Sg,.� icensejff2j�g3 Phone,&C=� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DE Q RECONDITION C3 DESTRUCTION M <br /> WELL CHL RINATION WELL ABANDONMENT 0 OTHER 0 00 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES ' -Flj:PRi-VY------- <br /> SEWAGE DISPOSAL FIELD&T""- CE%�LtSE P GE I� T OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL.�M6/- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �COX&TRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia; of We '1 Excavation <br /> Domestic/private Drilled Dia: of Well Casing <br /> Domestic/public Driven Ga'u,ge of Casing LO <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection — Rotary Type'; of Grout ' <br /> Disposal Other Other Information <br /> Geophysical SurWe+Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ta ", H.P. <br /> PUMP REPLACEMENT: p State Work Done ..�, <br /> PUMP REPAIR: Q 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 accordanc <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 FORA GROUT INSPECTJON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: :-chi DATE: <br /> (DRAW PL T PL N ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I fP � z.1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1426 Ppv- 19-77 1 78 2M <br />