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SAN JOAQUINLOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.257— -160 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued3 3� <br /> ` This Permit Expires .1'Year From Date Issued ` <br /> E 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. n <br /> EXACT STREET ADDRESS. r q D 4 IS ( A 1.J CITY/TOWN <br /> Owner's Name Lr �' �� cc Phone <br /> Address $ city <br /> Contractor's Name Q License# 2, Phone <br /> f . <br /> i <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE ',OE WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [] DESTRUCTIONj, ) <br /> WELL CHLORINATION [3 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [� � <br /> DISTANCE TO NEAREST: SEPTIC TANK+J,v� SEWER LINES+ L _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /Z.,? ` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/&. PRIVATE DOMESTIC WELL34%;.-!— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing C- <br /> Irrigation Gravel Pack Depth of Grout. Seal ;-z, cr <br /> Cathodic Protection �tary Type of Grout i3 X36! Y� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed :- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H-.P. <br /> PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia 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 Jdaquin 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 Wprkman's Compensation . <br /> laws o al ' rni <br /> I WILL CA FO G T NSP ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN 0 TITLE: ;° DATE: <br /> DR W PL T PL N ON REVERSE SIDE <br /> PHASE I F DEPARTMENT ENT USE ONLY . 1 <br /> APPLICATION ACCEPTED BY .�IDATrzxrJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I-II FINAL INSPECTION <br /> INSPECTION BY,,02� _ DATE 3-3�, 7 INSPECTION BWI-,,)X-,_ DATE 3--�o 2� <br /> E1 <br /> EH 147h ' Peiv 19_77 70 'A4 <br />