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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No-2 2 � 99 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete 1n Triplicate) <br /> Application is hereby made to the Sari 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. 11b6_ <br /> EXACT STREET ADDRESS 4,SD Ff Aio,�b or+�_ Civ Ft 7 01 V41Pds CITY/TOWN_ <br /> Owner's Name P. LcssSt�Nr Phone <br /> Address -rAokAcm tc_ _ CitymW (, 4bov;,4osi <br /> Contractor's Name ^},��,,,),�, per, /�. pC-8ox_-7o_c) License# Phone <br /> I-S CERTIFICATE OF WORKI'AIAN S COJ PENSATI0'N VISURANCE ON FILE WITH SJLHD. YES NO <br /> TYPE OF WORK (Check) : NEW WELLU DEEPEN 0 RECONDITION ❑ DESTRUCTION( <br /> WELL CHLORINATION 0 WELL ABANDONMENT-CI OTHER 0 <br /> PUMP INSTALLATION D PUMP REPAIR 0 PUMP REPLACEMENTiE) <br /> DISTANCE TO NEAREST: SEPTIC TANK �fAul .'SEWER LINES PIT PRIVY <br /> ES <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> -. INTENDED USE TYPE OF WELL 5 CONSTRUCTION SPECIFICATIONS <br /> _ _ X Industrial Cable JTaol Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing1,3 <br /> Domestic/public Driven _ Gauge of Casi ng,36" wow <br /> -Irrigation --- - --Gravel Pack- 4 -Depth-of:Grout Seal , <br /> Cathodic Protection Rotary _ Type of Grout Cewe <br /> Disposal Other Other Information <br /> Geophysical r Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> { <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 3/9 .' Approximate Depth/qcz � <br /> _._ Describe ML and Procedure 1,77W Cs6 vwl 'fie (_u4 { 7 0,rle .r <br /> U�. C'v NNQ f1 IG w6j -A Ltt 6v&u \A01 1.1-6- <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 /> s 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 /> TWILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDezA0TITL-&- 1 DATTE fe,, <br /> DRAW PLOTJLAN ON REVERSE SID' <br /> PHASE - <br /> FO ,PARTMENT USE ONLY <br /> I <br /> APPL!CATION� ACCEPTED B DATE . <br /> ADDITIONAL COMMENTS <br /> PHASE 11 GRO!'T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> LH 14 26 Rev. 9/78 - 5./7tri <br /> 9 <br />