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SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> 4 FFI E: 1601 E. Hazelton' Ave. , Stockton, CA 95205 Permit No. <br /> t fV41' Z �, z e , Telephone: (209) 466-6781 <br /> d <br /> APPLICATION FOR WELL CONSTRUCTIQN OR PUMP PERMIT Date Issue -Z=,a-,Z.q <br /> ` This Permit Ex ires 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 3 (o ,uac GI TY/TOWN_Sr oCiCTa,v <br /> Owner's Name ) L S 0 IU i Phone -2-1 -- <br /> Address City STa C/(V <br /> Contractor.'.sw-NameT � � &:L- LL.o_. �� .- �.---License#.. - (�8 Z:_;Phone , 2- <br /> � 3�.. <br /> f IS C-ERTIFICATE QF WOF:KtiAPd'S COt4PENSATIO'l I�ISURAt10E ON FILE �llTll SJLHD?� "lY..ES yL� 'NO �7�� <br /> TYPE OF WORK (Check):NEW W LL 'EEPEN ❑ RECONDITION ❑ DESTRU-CTION 0` <br /> 'MCM CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0' <br /> PUMP INSTALLATION ❑ PUMP REPAIR EJ PUMP REP;LAC.EMENT,Q. <br /> DISTANCE TO NEAREST:, SEPT:I:C TANK_J Q SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL <br /> Industrial � CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well—Excavation�_f f <br /> Domestic/private Drilled . Dia, of Well Casing Q �� -4 <br /> estic%public Driven„ ; ' y Gauge of Casing <br /> Irrigation Gr Pack Depth of Grout Seal <br /> �Catliodic"Protection otar <br /> Disposal Other Type of Grout <br /> Other Information 7 <br /> Geophysical Surface Seal Installed b <br /> PUMP NSTALLATI.ON: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; ❑State Work Done <br /> PUMP. REPAIR: _ OState Work Don—e' <br /> DESTRUCTION OF WELL: Well Diameter - <br /> Describe Material and Procedure Approximate Depth ISL <br /> } <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 Locall <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 sha h <br /> not employ any person in such manner as to become subject to Workman's Compensation. <br /> laws of California." <br /> I WILL CAL FOR A GROUT INSP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDf <br /> TITLE: d(, O DATE: Vi-ti' ) 7q <br /> DR W PLOT PL N ON REVERSE SIDE <br /> PHASE I FOR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY IML�ZNSP�CTIQ[N-�'�'"" <br /> -- DATE. :.r M " '�"NSPECTION BY_�h_ Qu MW DATE ���u� <br /> EH 1426 � � m-,Rev. I2-77 .1 . ;.� d. �tm l�e .� <br />