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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No.`7 LL420 <br /> Telephone: . ..(209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued q-#�7 _ <br /> This ,Permit Expires I 'Year .From Date Issued 0160'49 1 <br /> Complete In Triplicate f?— <br /> GI`7�" �fits P+ , <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- app=l'ication is made in compliance with .San <br /> kloanui n County'--Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. —AO ��CITY/TOWN , ,� O- <br /> EXACT STREET ADDRESS. �' .� � �-. CLIA/6L/ <br /> Owner's Name '' ,� G Phone <br /> Address. Gt T L _:� �. G� City <br /> Contractor �� '�� eiroI- i ce3d�'flone �/6�— �r� c <br /> .Sfd sty a � � �. <br /> IS`qCERTTFICAT�' same nse#F WOIMQlAN S CO,1PEt�SAT 0�1 i�1Sl to"CE ON FILE WITH SJLHD? YES NO <br /> i <br /> TY4 `0F WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j � ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 V . <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 <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 <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 /> GeophyNNsicAl Surface Se.Al Installed by: _ <br /> PUMP NSTALLTATION:A V Contractor <br /> Type of Pump H.P. 2�Q <br /> p64 REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 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 alifornia. " <br /> I WILL CA GR SPECTION PRIOR TO GROUTING AND A INAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> T 6,r7 <br /> W PLOT PERT ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS,- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Al INSPECTION B DATE 7,48 <br /> r i i I A^ <br />