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41 <br /> SAN JOAQUIN, LOCAL. HEALTH DISTRICT <br /> FFICE USE: 1601. E. Hazelton. Ave-.,- Stockton, CA 95205 Permit No.7f-j 2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Th 3 s„Perms t,'Ex i res. I .Yea,r., From Da I-s`sued , <br /> .. <br /> aComplete ,In Triplicate <br />(Application is hereby made to the San Joaquin Local Heal th. Di.s tri ct for a pe.rmiti,to-%construct <br /> and/or i As-ta l.l- they work heroth described. This ,appl i;cati on is -made; .i n compI i ante with. San <br /> %_cani;n County Crd.inance' "o x1862 and the Rules and Regulatio of th San oaquin. Local Health <br /> District. <br /> EXACT STREET^ n ESS -w_' 05 CITY/TOWN <br /> Owner' s Name 1.1 SS have 36A.-- <br /> Address, FC46 P #CLBI�J ,. rtwa. Ci ty L, o C{ �. . : G.3--C9 <br /> Contractor's Name -0 Q, License#.c. 3 Phone — 6�. <br /> > S CERTIFICATE OF 'WOgK1iArd`S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES ✓ 110 <br /> "TYPE' OF WORK (Check) : NEW WELL❑ DEEPEN ❑ ~RECONDITION M DESTRUCTION❑^ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER5jL . pLAvm4 It fiMA4 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEME T ❑ <br />` DISTANCE TO NEAREST: . SEPTICTANK 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 OFWELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 x Other Information Q <br /> Geophysical :' ce Seal Instal ed by., <br /> {a <br /> PUMP Contractor �. y�. v� ..`. S <br /> Type o' Pump . H.P. 40 1 <br /> PUMP REPLACEMENT: [] StaIte Work Done <br />! PUMP REPAIR: i A <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc be 11aterial an ,Pr e r'. I hereby certify that I have prepared 'th a I le <br /> n and that the work will be ne in accorda <br />'With San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc 1,_ <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 oy y person in such n as to become subject to Workman's Compensation <br /> law of Cali rnia.” I <br /> I WILL ALL FO ROUT NS T IOR T NG AND A FINAL INSPECTION <br /> SIGNED . TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE- SIDE) <br /> F R D PARTM rT U5E ONLY ,. - • - -- -� <br /> PHASE I <br /> APPLICATION ACCEPTED BY .4--, DATE <br /> ADDITIONAL COMMENTS : t <br />{ PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE — <br /> tiFu i a9r, Mau I')_77 — _ 1 MT 2M <br />