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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR FFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ! <br /> Telephone: (209) 466--6781 Date Issued /- - 7 <br /> I MS <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 Dtract inrict orca plimit to construct <br /> and/or install the work herein described. This application is <br /> Joaquin County Ordinance No. 1862 and the Rules and ,Regulationswith San <br /> of the San Joaquin Local Health <br /> District. CITY/TOWN sFD "C QZJU <br /> EXACT STREET ADDRESS 3 �C � <br /> L Phone 131—336 { <br /> Owners Name City <br /> Address a <br /> L ' (!,Q 1�J�,- Li cense# OL Phone <br /> Contractor's Name L L <br /> _ ATE OF WORKMAN'S CO"1PENSATIQIa INSURAtICE ON FILE WITH SJLHD? YES No <br /> IS CERTIFICATE -- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER( <br /> plMP IN TALLATID1V_[ PUMP REPAIRP_REQEENT Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ _ PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of Well Excavation Ids <br /> rivate Drilled Dia. of Well Casing IL <br /> Domestic/p Dri n � � Gauge of Casing <br /> Domestic/public <br /> E Irrigation avel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta] ed b <br /> t , <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> �N�R A ! , <br /> PUMP REPLACEMENT: E]State Work Done <br /> PUMP REPAIR: p State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter M <br /> { Describe Material and Procedure <br /> Y _ 1 <br /> I herebycertify that I have prepared this application and that theawarl� will be `done in accordant <br /> 1 9- - <br /> E with San Joaquin County Ordinances ; State Laws, a.nd Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner-or—licensed agent' s signature certifies the following: <br /> Distri . e work- for which this permit is issued, I shall, <br /> "I cDistri 'tin the performance of. -the <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. f <br /> TITLE: Lt) DATE: �7 <br /> SIGNED p PL L N ON REVS E SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> t .x.. <br /> PHASE I }L " ` DATE 1- `�- <br /> APPLICATION ACCEPTED BY �- <br /> 4 ADDITIONAL' COMMENT'S:`— <br /> PHASP II GROUT INSPECTION �`:�� � -+ PHAS I I INAL INSPECTION b� <br /> INSPECTION BY , DATE 6�1 INSPECTION BY <br /> 70_77 <br />