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SAN JOAQUIN LOCAL HEALTH DISTRICT --- ,_ <br /> USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. _5FIOFFICE <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. <br /> Date Issued 'oZ� <br /> This Permit Expires 1 Year From Date issued <br /> Comp ete In Triplicate) ; <br /> Application is hereby made to the San Joaquin Local Health' Qlstrict4 rmit, to tonstruct <br /> and/or install the work herein described. This application ismade in compliance with San <br /> Joaquin County Ordinance No. 1862 andtheRules and Regulations of the San Joaquin Local Health <br /> District. s. <br /> EXACT STREET ADDRESS � f . .., ' - °° .:. <br /> ,� TY/TOWN H)9 - ;t4 <br /> Owner's Name �" l t Phone ./ ' <br /> Address .�' / y► cityc s , .� <br /> Contractors Name ". i ? T"., <br /> , . <br /> Li cense Phone ., w <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAiaCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check): NEW WELL- DEEPEN❑ 'RECONDITION ❑' DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 59, <br /> PUMP INSTALLATION. ❑ PUMP REPAIRCI PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSWL/SEEPAGE IT_ OTHER <br /> PROPERTY LINE PRI'VAESTIC WELL ` PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigationr Gravel Pack Depth of Grout Sea <br /> - Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical r. Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ' " ro 711 .777- <br /> 7 <br /> Type of Pfart� s. . <br /> .. <br /> PUMP.RREPLACEMENT: []State Work Db <br /> PUMP REPAIR: � .. <br /> ❑State Work Done - <br /> . <br /> DESTRUCTION OF WELL: Well 'Oiameter <br /> 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 FOR A GROUT INSPECTION. PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE:. _ DATE: <br /> ��LOT PLAN ON REVS , <br /> FOR RFAMENT USE Y <br />)HA$E I <br /> 4PP I ATION ACCEPTED BY <br /> -- A?6" �.�r� DATE J7 B <br />%DDITIONAL COMMENTS: /� ,,,,ic ���/ t�nuaf / h� �6 r <br /> PHASE Ii GROUT INSPE TION PHA I F' AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --a-lomoi. <br />-H ]422. <br /> 1178 2M <br />