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SAN JOAQUIN LOCAL HEALTH DISTRICT ;y <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -7q-66/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (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. > <br /> EXACT STREET ADDRESS 0,t- 45. 0t'4 r10, �d CITY/TOWN <br /> Owner's Name-Aro- , Phone e7 <br /> Address City <br /> Contractor's Name `ck t U9-f CL- 1 N4 Li cense# 123 Phone 34, 9-1t, 74? <br /> IS CERTIFICATE OF WORKMAN`S CO";PENSATION INSURANCE ON -FILE-W.ITH"SJLHD?— YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [3RECONDITION ® DESTRUCTION(n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ® OTHER ❑ _ - <br /> PUMP INSTALLATIONS 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 Toa! -Dia.' of Wel Excavation <br /> _Domestic/private Drilled - . . Dia: of Well-Casing" <br /> _e <br /> Domestic/public Driven i Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Sea \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical r Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 'Atil iti 1� �Lr -We-Yjc <br /> Type of Pump H.P. ,?A& <br /> PUMP REPLACEMENT: j=State Work Done - -Ei i 3 <br /> PUMP REPAIR; ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter L -` _,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 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 California. <br /> I WILL CALL FOR A, GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: �o " f_l�- fig <br /> N ON REVERSE SIDE <br /> PHASE I <br /> F R DEPARTMEN USE ONLY <br /> m <br /> APPLICATION ACCEPTED BYSIL� A4DATE �o l <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTI N I PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE 3 <br /> CH 14 26 Rav_ 4/7R CY17R 7M <br />