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C— <br /> SAN JOAQUIN LOCAL HEALTH DI.STRICT <br /> EQR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA - 95205 Permit No 7 9_ :3� <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -) <br /> This -Permit Ex ices 1 Year From Date Issued <br /> Complete In. Triplicate <br /> 4 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 i5RiU et, CITY/TOWN_S-6 C1CTS <br /> i Owner's Name eaLo I VL Phone <br /> I Address 7Kk,,_,R1Q Ci ty ra I f►� <br /> Li cense# Z Phone 6�— <br /> Contractor' s Name L C Ul�- F s _ t <br /> IS CERTIFICATE OF 130PKMAN'S COMPENSATIO`J INSURAINCE ON FILE WITH SJ4-HDZ YES . ANO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITTONTI - MESTRUCTI.ON.[y _ <br /> WELL CHLORINATION 0 WELL ABANDONMENT M_ —OTHER'O <br /> PUMP INSTALLATION Q PUMP REPAIR P LMM REPLKC.EMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK IV SEWER LINES i PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -CESSPOOL./SEEWA`GE PIT t OTHER I <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USES ',T,YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation � " R <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing #/Z <br /> Irrigation I Pack Depth of Grout Seal 210 1 <br /> I Cathodic Protection Rotary Type of Grout CIC Liz <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUM RP RP EPLACEMENT F []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth; <br /> Describe Material and Procedure <br /> f � <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 SanJ.oaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: I"-, <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 CAL FOR A GROUT INSPE ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 6L DATE: s <br /> (DRAW PLOT PLTNI ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I z <br /> - <br /> APPLICATION ACCEPTED BY u--�C w DATE y I <br /> ADDITIONAL COMMENTS: d <br /> PHASE II GROUT INSPECTI N PHASE_JII _F4AL INSPECTION <br /> I INSPECTION BY p DATE ` : a `,INSPECTION <br /> ru 1ngg D-- 1077 - 1/:78--_;.'2M <br />