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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issued�l 1 <br /> n. <br /> This Permit Ex ires 1 Year From Date Issued , <br /> Complete In Triplicate <br /> 4pplication 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 />'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. /n <br /> EXACT STREET ADDRESS S3 3 7 Ajaj 1d Ka Grl CITY/TOWN <br /> Dwner' s Name .�, r , _ �+� 'tte, Phone _ <br /> Address ,r—;;1 A Z h otl& W 6 r-0 o�4 n?5 C i ty � � <br /> Contractor's Name �° 1COEfl;SATIO','1 <br /> ,� -"°" License#/92?-.1"Phone �z�Gi 2,9 ^� <br /> IS CERTIFICATE OF WORKMAN'S I�1SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ w <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER FJ <br /> PUMP INSTALLATION ❑ PUMP REPAIRCR PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER =. <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )c Domestic/private Drilled Dia. of Well Casing` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor u <br /> Type of Pump ue H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: [RState Work Done L-Jo /Ye N-) k10 L/ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 INSPEC ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE4� '" , ITLE: DATE: <br /> W PLOT PL N REVERSE SIDE <br /> FOR KPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY tic DATE `� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTI <br /> INSPECTION BY % 1 (- DATE INSPECTION BY DATE OK114 <br /> EH 1426 Rev. 12-77 1/78 2 <br />