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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: <br /> P (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTTON. OR PUMP PERMIT Date Issuedg_g_ g' <br /> This .Permit Expires I Year. From Date Issued <br /> ,,j�,,.t (Complete <br /> 3 s - �P�,� �� In Tri pl i cafe <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 /> ioaQuin County Ordinance No. 1862 and the Rules and R lations of the San Joaquin Local Health <br /> i <br /> District. �Yp 5rld�eSs <br /> x <br /> EXACT STREET ADDRESS 3'b �KD st t^�,d/�i6� � � ' CITY/TOWN- E.s <br /> Owner's Name -- - <br /> C, -t d U r o. ® Phone =S::f -- 357Z z <br /> AddressT C_'t ���- �� . <br /> City. O.J <br /> Contractor's Name $ License# Phone ,sem <br /> IS CERTIFICATE OF 'WORKMAN'S COMPENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK_.(Check) :. _NEW,.WELL,C]..,_ DEEPEN0--rARE.COND:-U.10N 0.-,!m-DES-TRUC'TIONQ -�. <br /> -- - WELL CHLORINATION 0 . WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION - PUMP REPAIR❑ PUMP REPLACEMENT Do <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER AS ' <br /> PROPERTY LINE -, PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL w <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS h . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia, of Well Casing <br /> ___,___Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout —Seal . Z_ <br />—Cathodic Protection Rotary Type of Grout <br /> bisposal Other Other Information <br /> Geophysical Surface Seal Installed by: - <br /> PUMP <br /> :PUMP INSTALLATION: Contractor 4-S <br /> Type of Pump :°�V I _ H.P. 1 <br /> PUMP REPLACEMENT: X State Work Done c e- .214P rp4 W <br /> PUMP REPAIR: - r <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate ,Depth, <br /> _Dd`scF1'6e'_M6_t6rial and Proce ure - - - - -� <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 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 /> --------------------------------- <br /> SIGNED TITLE: � DATE: <br /> DR W PLOT L N ON REVERSE TDE <br />)HASE'I FOR DEP TM T USE Y <br /> APPLICATION ACCEPTED BY <br /> kDDITIONAL COMMENTS: DATE <br /> r <br /> PHASE TI GROUT INSPECTION - , <br /> NSPECTION RASE III FINAL IN <br /> BY SPECTION <br /> DATE INSPECTION DATE /.. 7a <br /> H -14.26 Rev. _12-77 <br /> QED - - <br />