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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EQR FFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No.7 9-2 99 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -3-2 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate • <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 /> 2oanuin County Ordinance No.y1862 and the Rules and Regulations'of the San Joaquin Local Health <br /> District. 14 i <br /> EXACT STREET,ADDRESS S. �p�/ �L/��,�. CITY/TOW�� <br /> Owner's Name 4 u F Phone <br /> Address a, A/&L) city Kyr f <br /> Contractor's Name �b�r ,S�Sii�/ License#P?'98/h Phone .ZW <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK -(.Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ FDESTRUCTION Q <br /> ZWELL' CHL'ORINATION 0 WELL ABANDONMENT E3 OTHER 0 <br /> PUMP INSTALLAT.I.ON.0__._P_& REPAIRCR PUMP REPLACEMENT-0_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY c? \ <br /> �,SEWAGE,DISPOSAL. F,IELD S CESSPOOL/SEEPAGE PLT_ —OTHER <br /> 'PROPERTY LINE PRIVATE DOMESThC WELL___L PUBLIC DOMESTIC WELL <br /> •..,a 't . �'. �.e N J •-1 •.- <br /> INTENDED USE ` TYPE OF WELL C CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation <br /> Domestic/private Drilled Dia. of Well ,Casi'n"gl <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _,Rot Type Type of Grout <br /> T <br /> Disposal Other Other `Information <br /> Geophysical Surface Seal . Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> \Type of Pump H.P. <br /> c. <br /> PUMP REPLACEMENT: I0 State Work Done <br /> PUMP REPAIR: 5E State Work Done ft,4,,�e AeLA�Vlli - - J DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateriaProce ure <br /> I hereby certify that I have prepared this application and that the work will be done in ace <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaqui <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 CAL6aR a G UT JASPECTION PRIOR TO GROUTING AND A FIN L, INSPECTION. <br /> DATE: <br /> SIGNED TITLE: J' 9 <br /> k <br /> [6TFTL7CN ON REV R E SIDE <br /> FOR VIRTMENT USE ONLY i <br /> PHASE I �� DATE Vt 3' 7 7 <br /> APPLICATION ACCEPTED BY�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /-2- <br /> q <br /> S�L <br />