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SAN JOAQUIN. LOCAL HEALTH DISTRICT �- - <br /> Stockton , CA 95205 Permit No. S`- <br /> FOR FFICE USE: 160I E. Hazelton Ave.. , ,w <br /> Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit x fires 'I Year From Date Issued <br /> _ Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health D7stride for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br />,,oacauin County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health � <br /> District. s� i <br /> EXACT STREET ADDRESS IV� 'o cz/ S : JPc CITY/TOWN 4..,�& <br /> Owner' s NamePhone -- F <br /> Address a en Ci ty: r I <br /> Contractor's Name �l:.i cense#2 Phone , <br /> IS CERTI-F-IC-ATE-O-F-WORKfiAN-'-S-COt1PEIISAT-I'0"l I,ISURA"cICE"OPJ-,FI'LE'WIT1i-SJLHD? YES rf0" <br /> TYPE OF WORK (Check) : NEW WELD DEEPEN ❑ RECONDITION [❑ - - DESTRUCTION <br /> OTHER FA <br /> WELL .CHLORINATION 0 WELL ABANDONMENT PUMP REPLACEMENT ❑ <br /> PUMP INSTALLATION WL, PUMP REPR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OgeSEWER LINES AW-06PIT 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 /> Cable Tool Dia. of Well Excavation_ v p <br /> Industrial' <br />' Domestic/private Drilled Dia. of Well Casing - — <br /> a Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary_ Type of Grout <br /> F Disposal Other Other Information <br /> -..�.Geopby-sical . . ..:_.- <br /> ,Surface Seal Installed b : <br /> lip <br /> PUMP INSTALLATION: Contractor ' klryz <br /> Type'o <br /> , PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - - - Describe Material and Procedure <br /> 1I hereby certify that �I have prepared this application and that the work will be done in accordant <br /> -3with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> I <br /> ,.H,ealth <br /> 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 /> I not employ any person in such manner as to become subject to Workman's Compensation <br /> laws`of Californ7a.'1__ cam' <br /> kI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED M=4 41 .'...TITLE: DATE: <br /> DRAW PLOT L N ON REVERS SDE <br /> i FOR DEPARTMENT USE ONLY <br /> 4PHASE IDATE �r 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ <br /> DATE INSPECTION BY �ATE <br /> 1/78 N 2M <br />