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V/ SAN JOAQUIN .LOCAL .HEALTH DISTRICT <br /> OFFICE USE: v 1601 E. Hazelton Ave. ,; Stockton, CA 95205 Permit No. /[S4Z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,,,7-,;_5_-7 <br /> This Permit Ex ires 1 Year From. Date Issued <br /> Complete. In Trip irate <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 />.oaouin County Ordinance No. 1862 and the Rules and• Regu 1ations of the San Joaquin Local Health f <br /> EXACT STREET ADDRESS �'L �!/' CITY/TOWN <br /> Owner's Mame Gt/;`L1,�`,� o rsi d Phone <br /> Address an City . <br /> Contractor' s Name Lar W .0 DAe4/-1AJG Licensef,.?so iy' .�_ Phone3(;,P'-- ! Gp 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO-x <br /> TYPE OF WORK (Check) : NEW WELLJO ' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO 'NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER w� <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 �2 �r <br /> yf Domestic/private Drilled Dia.°: of Well Casing <br /> Domestic/public Driven .i Gauge of Casing /2 G.09. --a <br /> Irrigation Gravel Pack Depth of Grout Seal d t_ <br /> Cathodic- Protection Rotary Type of Grout f4 .CA/T <br /> Disposal Other Other Information <br /> Geophysical .' . Surface Seal Installed b ,44 E/c- I <br /> PUMP '-INSTALLATION: Contractor fi j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION 'OF .WELL: Well Diameter Approximate Depth - <br /> Describe-Materi-a '.-an - Procedure <br /> I hereby certify that I have prepared this a.pplicat.ion 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 subjecto'to Workman' s Compensation. ,� <br /> laws of California. " <br /> I WILL CALL FOR A GROINSPECTION P TOR TO GROUTING AND A FINAL-INSPECTION. <br /> SIGNED - -" TITLE:C-& DATE: S—7 <br /> DR W PLOT PLAN ON REVERSE-OSIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /J <br /> APPLICATION ACCEPTED BY oma-• ,Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHA,V IV GROUT INSPECTION PHASE III., FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE `7 -')Jy7� <br /> --• - --- - - - - . T/'7R 7M <br />