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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 4666781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 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 l G 0 2 y i-j - Rc p ojv j) o Pot • CITY/TOWN_TA M c,Y <br /> Owner's Name �STff v&".r Phone .�.s`'- e F Z/ <br /> Address s''27 � � J/T�` City TA- )aC <br /> Contractor' s Name IT Z)i a-Tp-Ie­ License#/V71-�ov Phone i'-- /36 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOiN I'NSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION p WELL ABANDONMENT C3 OTHER 0 -- <br /> PUMP INSTALLATION PUMP REPAIR O 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 /> Domestic/private Drilled Dia. of Well Casing u <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 b <br /> PUMP, INSTALLATION: Contractor AIA ldT ZfL,re C _JL IC- <br /> Type of Pump 'k iWzH r g LX H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP!. REPAIR: (State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application <br /> 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 /> rSIGNED , e--e" TITLE: 9v!&ADATE <br /> (DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ^7 ._ <br /> iADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7- <br /> 1 _ -- 1./79-' 2Y� <br />