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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No._� C -+c 6 <br /> Telephone: (209) 466-6781 �"" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 6"­ 0-7q <br /> This Permit Expires 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 herein described. This application is made in compliance with San <br /> .'oapuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health I <br /> District. <br /> EXACT STREET ADDRESS3 MIR <br /> .---. CITY/TOWN SM C!C (Vi <br /> Owner's Name R ! ckai► vtf C-U ii Phone C7S7-41,,,) <br /> Address �.2 � . 1)7-0 t1G LVACity. 717_0CAr77AJ <br /> Contractor's Name KIQ.0 F a V10 C d, <br /> 71[ft,ense# 7�� Phone__ <br /> IS CERTIFICATE OF WO1tKt"iAtl-'`S--C'Ofi1PENSAT -0"I-IPdSURA}•ICE-LOt11FILE-W'ITH--S-JLHD?J- YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Ca PUMP REPAIR❑ PUMP REPLACEMENT [] c� <br /> DISTANCE TO NEAREST: SEPTIC TANK ;� SEWER LINEn-27Z PIT PRIVY S <br /> SEWAGE DISPOSA� IELD �� 'CESSPOOL/SEEkPE PIT OTHER'"'-- - f <br /> PROPERTY LINE/ PRIVATE DOMESTIC WELL 2 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. , ; % . , CONSTRUCTION SPECIFICATIONS <br />�ndustrial Cable' Tool +" 0'ia. of Well Excavation <br /> omestic/private Drilled Di.a. of Well Casing = . <br /> Domestic/public Driven - ,-,Gaugee of-Casing <br /> Irrigation , Gr el Pack • Depth of Grout Seal <br /> Cathodic Protection otary �. Type'if Grout Q <br /> Disposals Other , -- I.._ . Other Information <br /> Geophysical ;� Surface Seal , Installed by: <br /> PUMP INSTALLATION? Contractor <br /> Type ,-Pump , H.P. <br /> PUMP REPLACEMENT: M'State Work Done ' <br /> PUMP REPAIR: CD State-WorkTDo._ne <br /> DESTRUCTION OF WELL Well Diameter <br /> Approximate Depth <br /> Describe Materia an Proce ure f <br /> -. . <br /> I hereby certify that Oha`ve"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 />-lealth 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 CAL F A OU INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 5 <br /> iIGNE1) TITLE: DATE: <br /> (DRAW PLOT PLTN ON REVERSE SIDE - 1 <br /> FOR .DEPARTMENT USE ONLY <br />'RASE I <br /> APPLICATION ACCEPTED BY r DATES 2v :may <br /> ADDITIONAL COMMENTS : <br /> PHS II, GROUT INSPECTION PHASE II FINAL INSPECTION <br /> NSPECTION BY DATE 6 ',P--5 '?y INSPECTION BY -V - DATES" -. <br />