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I' C. <br /> SAl!-JOAQUIN -LOCAL,,.HEALTH DISTRICT <br /> F..FICE USE: 1601 E. Hazelton Ave.-, Stockton, CA' 95205 Permit No.79- 3 _ <br /> Tel epho.ne,:_._QQ9) 466-6781 <br /> �. Date Issued -X -7 E. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued ` <br /> ,I1. Complete In Tariplicate <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 R6gulations of the 5an..Joaquin Local Health <br /> District. O r7�(/l i -IV -Of <br /> PE`s�Fe- onl 'T.eETW - <br /> �p 5-e7 v✓ dF' 77is- 6X.7 vsioAl CITY/TOWN f"f <br /> EXACT STREET ADDRESS ,� D <br /> Owner' s' Name gi2L/N A: ,4ZE , , t Phone (o <br /> Address-j.,' Q!/BD. D U, ,. City_ <br /> Contractor' s NameEL.L� 0,0 <br /> .tlC Li cense#3 ��Ehone - 3 <br /> IS CERTIFICATE; OF WORVAN'S CO'clPENSATION INSURANCE OIi-F-ILE :vITLI SJL4o`f YES N0 <br /> -'— ' W <br /> . <br /> TYPE _0_F', @0=RK - NEW WELL CI DEEPElyZ RECONDITION, DESTRUCTI.ON-1 <br /> WELL CHLORINATION C3 WELL ABANDONMENT E3 OTHER d"— <br /> PUMP <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPL'ACPE' NT p <br /> DISTANCE TO NEAREST: ' SEPTIC TANK �D SEWER LINES �P T PRIVY- ---- <br /> SEWAGE DISPOSAL F ELD '--- CESSPOOL/SEEPAGE PIT ..�-- 7�HER <br /> PROPERTY LINE RIVATE DOMESTICSWELL ----—PUBLIC DOMESTIC WELL „._ <br /> 'INTENDED USE TYPE O1 WELL CONSTRUCTION' SPECIFICATIQNS <br /> ::Industrial _'Cable Tool Di,A. of Well EX-Cavation..' _�:� <br /> iDomestic%private Drilled Dia. 'of Well Casing -V- .isr� C ` � <br /> Domestic/public Driven Gduge of Casing a <br /> i Irrigation Gravel Pack Depth_of Gr-ou Sear So`�` <br /> k .:Cathodic Protection Rotary Type of Grout ', ;,.--, <br /> Dis p_osal _Other -�_. _ ._-. Other Information <br /> _ -� - <br /> al l ed b Ge.o.ph -S.urface Seal Inst <br /> -y_ a <br /> PUMP . <br /> INSTALLATION: Contractor <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> j_DESTRUCTI.ON OF WELL: _ Well Diameter _.Approxi.ma.te_Depth-._._-.__---,-y <br /> k rDescribe Materia an Proce ure <br /> , <br /> I hereby certify that I have prepared this application add that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules`1'and Regulations of the San Joaquin Local <br /> HealthlDistrict. Home owner or licensed agent' s signature' certifies the following: <br /> "I certify that in the performance of the. work for which thiss_permit,is issued,�I shall__ <br /> not employ •any�person�u--c manner as,to become suUject to �l�rkman' s Compensation <br /> laws of California. x <br /> t I WILL:. CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND, A. FINAL INSPECTION. ` <br /> SIGNED TITLE: DATE: ¢-17=�� <br /> 4 <br /> (DRAW PLT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE �I ` � - DATE= 7�' /� <br /> ' APPLICATION ACCEPTED BY <br /> , _2 Q <br /> - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F PHASE III FINAL INSPECTION_ <br /> INSPECTION BY DATE . 7 y INSPECTION BY D�jTE <br /> �i�t� <br /> 1- 7 8 2M, <br /> cu 1n!)r, Do 19_77 <br />