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t SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit No. �/� <br /> C Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fres 1 Year From Date Issued <br /> (Complete Inrip icate zp3 0(,0 <br /> fist o-C 1 <br /> 4pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinidescribed- This application-is made in compliance with San <br /> Joaquin County Ordinance No. 62 and the Rules and Regulations of the San quip Local Health <br /> District. � ,(, eil DO <br /> EXACT STREET An �" - CITY/TOWN HH•A/a+e_ca, <br /> Owner's Name Agr V Ari Phone <br /> Address 13799 G/J��/�o�.r/ �w ,9iio City /i�iPv J <br /> Contractor's Name /U" License&; T Phone _5?f 16M <br /> IS CERTIFICATE OF WORYOMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X. NO J <br /> TYPE'OFWORK-.("64ck): t id:WEEL--L_I DEEPEN ❑ f-RECONDITION Q DESTRUCTION 171 s <br /> WELL CHLORINATION' WELL ABANDONMENT 0 OTHER C.] <br /> PUMP INSTALLATION PUMP REPAIRCJ PUMP REPLACEMENT O F <br /> DISTANCE-TO -NEARESTSEPTICiTANK -SIWER LINES PIT PRIVY O <br /> SEWAGE DISPO�F )ELD CES5TffiL/SEEPAGE PTT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL — PUBLIC60�IESTIC WALL \! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS e <br /> I <br /> —Industrial e= ool Dia. of Well` Excavation 'l ? <br /> Domestic/private Drilled Dia. of Well Casing p <br /> Domestic/public E Driven Gauge of Casing <br /> Irrigation A Gravel Pack Depth of Grout Sea i? <br /> Cathodic Protection ! Rotary- Type of Grout <br /> Disposal j Other- 4„,Other Information <br /> Geophysical 11 Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump2tr' j°aP <br /> PUMP REPLACEMENT: Q State Work gone. <br /> PUMP REPAIR: ©State Work Done <br /> ` DETTRUCT'I�N OF WELL: v Well Diameter ,, ,/ Approximate Depth, <br /> Describe Material and Procedure <br /> I hereby certify that I hav64r6ared this?application and that the work will-be db a in accordance' <br /> with San Joaquin County Ordinances , State 8:aws, and Rules and Regulations of the San Joaquin Local <br /> Heal thxD'i-s-tri_ct. Home owner=or -licensed agent's signature certifies the following: <br /> i "I certify th'at-inthe performance.;of the work for which this permit is issued, I shall <br /> not employ any pers`onn such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A,4ROUT INSPECTION .PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE. _ DATE: Q _ <br /> PLOT TEWON REVERSEW— <br /> OR DEPARTMENI ..UbL UTICY <br /> 'SE If <br /> 1.,Cr ICTION ACCEPTED BY �B L!�pt DATE y"f`'af <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI'ON�`_ ” PHASE 1111VINAL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE s" 1-7, <br /> J/ <br /> ICU 1n0< -oe... �o._» No{-3 .0-3 - 1/78 2M <br />