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SW-JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR FFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781. <br /> - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> omplete In 'Triplicate) <br /> Application is' hereby made to the San Joaquin Local Health- District for,a permit to 'construct ­ <br /> and/or in'stall, 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 ,: N - " <br /> w <br /> NW ISE <br /> ' r R eT- Phone�iQq�93f -552D <br /> r � n <br /> Is N CityC'prt _ <br /> �- <br /> Contractor's Name 4 , License# Phoney�en o3 IIS 3 <br /> IS CERTIFICATE OF WORKMAN'S C01,11PENSITIO"�`INSURA"ICE ON FILE WITH'SJLHD? YES ✓,_1__ O. <br /> 1-1 <br /> TYPE OF -WORK (Check) : NEW WELL Cj <br /> __7 DEEPEN p RECONDITION Q DE RUCTION Q.. <br /> ^ WELL CHLORI-NATI.ONYQ WELL ABANDONMENTS OTHERM� Sedw►n6m+$61es <br /> PUMP INSTACCATIA ❑ PUMP REPAIR 0--"' PUMP"REPLACEMENT [3 -- <br /> i <br /> . DISTANCE...TO NEAREST: SEPTIC-TANKS WER_ LINES:.,_ _ _ PIT PRIVY j <br /> SEWAGEPOSAL FIEIrD CESSPOOL/SEEPAGE-P� OTHER <br /> --�'PROPERTY,.�L'INE--= -PRIVATE D MESTIC WELL -Y PUBLIC DOMESTIC WE—LL - <br /> 7 <br /> ELL ZI <br /> �- <br /> INTENDED USE CONSTRUCTION,SPECIFICATIONS } <br /> Industrial Cable Tool 'Dia. of Well Excavati"on a " H <br /> Domestic/private Drilled Dia. of Wel.I�-tasi ng <br /> Domestic/public <br /> i c- ' <br /> /p Driven Gauge of Casi g �y E ! <br /> Irrigation ravel Pack Depth of Grout .Seal N E. <br /> r <br /> Cathodic Protection Rotary Type of Grout J <br /> Disposal;_ Other Other Information <br /> _ -Geophysical , Surface Seal, Insta�b <br /> PU. R:�"IN�SALLATION: Contractor <br /> q Type of PumpH.P.- <br /> PUMP <br /> .PUMP REP AGEMENT: --Q State Work Done <br /> PUMP REPAIR: /A 'E]S.tate Work—•Done <br /> 'DESTRUCTION OF WELL"`'/Ye'.11 Diameter <br /> Z Ap roximate Depth to'- 15 r <br /> /Mscri6j Ma.terla an Procedure_ F- i s <br /> tfI hereby certify4,that-I,have prepared t is application and that the work will be one in accordant <br /> with-San Joaq"_6,County Ordinances , State Laws , and Rules and Regulations of the San. Joaquin Local <br /> HeaIth_ Dis.trict:` Home owner or-Iicensed 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 ma nn er-as to"become`suEal'e.ctto,Workman's Compensation <br /> laws o`fCalifornia." p <br /> I WILL C F GRO T SPECTION PRIOR TO GROUTING.-AND A FINAL INSPECTION- --_ : <br /> SIGNED '' T-IfLE <br /> ' W PLO PLN ON J-REVERSE <br /> x' FORD RTMENT'USE ONLY <br /> PHASE I -- - .- _ <br /> PPS LICATION :ACCEPTED BY DATE <br /> ADDITIONAL •COMMENTS : At <br /> PHASE II GROUT INSPECTION <br /> IINSPECTION BY PHASE III SINAL INSPECTION <br /> DATE INSPECTION BY ATE <br /> EH 14 26 Rev: 9 L 78 2M <br />