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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: ; 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._Zf=�7v <br /> -- i Telephoner (209) 466-6781 -` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From 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 hierein 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 ,Z g�l1�' lllfs- [ /f n C? T• CITY%TOWN r <br /> Owner's Name x lA<risj,.i Phone eF Z <br /> Address X Z 7 TH City I^ <br /> Contractor's Name W�' 'LK CI—A4G License#ff 7j. 'ov Phone <br /> IS CERTIFICATE OF WORKHANM'S C01,1PENSATIO'! I'NSURA'NCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN-OL, RECONDITION ❑ DESTRUCTION(D � F <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ �p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY cA <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 /> Geophysical Surface Seal Installed by: <br /> PUMP.. INSTALLATION: Contractor �nT GLeTxr � <br /> Type of Pump �� ani- - H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br />?UMP. REPAIR: QState Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth ! <br /> Describe Material and Procedure ; <br /> i - <br /> I hereby certify that I have prepared this application and that the work will be done in accordand <br /> Vith San Joaquin County Ordinances , State Laws:, and Rules and Regulations of the San Joaquin Local' <br /> lealth District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in thelperformance 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 />[ WI-LL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED ,dZ> M TITLE: an <br /> tf � DATE: <br /> i� <br /> (DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HAS_E I <br /> IPPLICATION ACCEPTED BY )J-4-9 � DATE <br /> kDDITIONAL COMMENTS: M <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> NSPECTION BY Ip DATE INSPECTION BY AkgtnZ DATV2— <br /> 1496 Rev-- 12-77 jN' 117A 9M c <br />