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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> MFICESE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. ;?Telephone: (209) 466--6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> -'� <br /> This Permit Expires 1 Year From Date Issued <br /> �l. Complete._In Tripl-irate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein- described. This, application is made in- compliance with San <br />.'oaquin County Ordinance ado. 1862 and the Rules and Regulations _of :the San Joaquin. Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> —200rethewa CITY/TOWN LockefQrd. .. <br /> Owner's Name m H-unzeker Phone_�c 4$,51 4 <br /> Address '., 827. E. Main St . City Stoakton 7,�- <br /> Contractor's Name License# 'HCl til p Phone � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"i INSURANCE .ON FILE WITH SJLHD? YES XXXX NO � <br /> �° OF WORK (Check ,- NE WELLL EEPEN CI �RECONDII ION � DESTRUtTION <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 W � <br /> PUMP -INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q Q <br />)ISTANCE TO NEAREST: SEPTIC TANK + `..SEWER LINES /A PIT PRIVY N/A <br /> SEWAGE DISPOIELD 1 So+ CESSPOOL/SEEPAGE PITS_ OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL64c-4,-, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation lit, a <br />�YDomeStic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br />-.Irrigation X Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _ x Rotary Type of Grout <br /> Cement �r- <br /> i Other Other Information <br /> Geopfiysica.1 Surface Seal Installed b :p <br /> tMp" TWSTA .i nrrnn:. Contractor <br /> " Type of Pump H.P. <br /> l <br />' -�'- []State Work Done <br /> []State Work Done t <br /> T5T1k1`MZ(7r14Ett:- - Wel,l Diameter- - - - - Ap.p.r_oxi_mate-Depth <br /> Describe Materia and Procedure -� <br /> hereby certify that I have prepared this application and that the work will be done in accordanceI <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin.Local '� <br /> ealth District. Home owner or licensed agent's signature certifies the following: <br /> I certify that in the performance of the work for which this permit is issued, I shall ' <br /> not employ any person „in such manner as to become subject to ?Workman's Compensation <br /> laws of..California. ” <br /> WILL CALL-f. GROUT INSPEqjj0N P ROUTING AND A FINAL FINSPECTION. <br /> IGNED / TITLE: Owner- Qnntr;;c,. DATE: 11/1�/7$ <br /> 14 <br /> DR W PLOT PITY ON REVERSE SIDE) J <br /> HAS E I ' US <br /> FOR DEPARTMENT E ONLY <br /> _.. - <br /> PPLICATION ACCEPTED BY �2 DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION y PHASE III FINAL INSPECTION <br /> VSPECTION BY , �_ DATE "--j- �(I INSPECTION BY DATE <br /> 1 1426. Rev.- 1'2-7 _ 1 17A -W <br />