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SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> FF.ICE USE; <br /> ,� �. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> - Telephone: (209),.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued��r�e -7©i <br /> Thi's Permit Ex 'Ires' 1 `Year.From Date Issued <br /> Comp ete In rip irate <br /> Application is hereby made to the San.Jdaquih. Local .Heal th Dist rict. for a permit to-.construct <br /> and/or install the work herein described. This app lication, is .made in compliance with San <br /> Joaqui-n •County Ordinance No. 1862- and. the Rules and Regulations of the San Joaquin Local Health <br /> District. w@, <br /> EXAC`C STREET ADDRESS ' -- gco <br /> CITY/TOWN 904 . <br /> Owner's Name_ Dvz-e Pon ] y <br /> Address <br /> .93S' 40LivE— E - ZIP 4 . 4- City <br /> 4 Contractor's Name�� � � lalEt_ "D�IGG` icense# pLZ R one -337 <br /> IS CERTIFICATE OF tJNWIAN'S COMPENSATIO`! INSURA" <br /> JCE ON FILE WITH SJLHD1. YES <br /> ".TYPE 0F=WORK'(-Ch6ck) : 'NEW-WELT=0-"- :.DEEPEN-G-x"�RECON-DITI'ON <br /> WELL CHLORINATION � ......�DEST�UCTI'QN� �-�-•---�-- <br /> PUMP.. ❑ WELL ABANDONMENT ❑ OTHER A=! <br /> � � Q PUMA REPAIR0 PUMP REPLACEMENT ❑ ;� <br /> DISTANCE TO NEAREST �SfRTIC TANK/M/' SEWERLIKES PIT PRIVY <br /> r,. <br /> SEWAG }DISPOS L TIELD -C-ESSP OL/SEEPAGE PITTOTHER <br /> PROPERTY LINE PRIVATE DMESTIC WELL PUBLIC DO ESTIC WEL�' N " I <br /> INTENDED USE 4 STYPE OF'WELL ? CONSTRUCTION.SPECIFICATIQNS ' �F <br /> k In ustrial ^! Cable Tool # Dia. of Well Excavation �sTy zr � <br /> Doan ,tic/private Drilled I Dia. of Well Casfn . ars; 142 <br /> —US�e vlt--/ - _� :«��.r�v�n= =-- t ��G 9" 3 <br /> ET3cathodic rrigatian � nq�rave1Taal Depth at GrouSea Protection Rotary Type of Grout <br /> Disposal Other ---r <br /> Geophysical Other Information wlzz_ �.vs7._t� 1,; /a , <br /> Surface Seal Insta� ed <br /> PUMP .INSTALLA'TION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCT.ION_.QF�WELL:.- _Weaa,D.iameter•._�.:= ...W ,, <br /> Describe Materia and Proced— <br /> ure <br /> -'�--Approxi.mateDepth <br /> I hereby certify that I .have prepared this application and that the work will be done in�a cordance� <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local ' <br /> Health District. Hoine, owne'r or licensed agent's signature certifies the following: ' <br /> "I certify that inhe performance of the work for which this permit is issued, I shall F <br /> not employ any pe, son in such manner as to become subject to Workman's Compensation <br /> laws of California." ,,{ I <br /> I WILL CAUA FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED + <br /> TITLE: HATE: -20"7 9 I <br /> ` L ON REVERS S + <br /> PHASE I <br /> R D R N U E NL <br /> TP—PLICATION ACCEPTE9,XY <br /> ADDITIONAL COMMENTS:. DATE <br /> PHASE II GROUT INSPECTION PHASE III <br /> INSPECTION BY <br /> FINAL INSPECTION <br /> DATE INSPECTION B <br /> '-� DATE;;21, 2g <br /> EH '1426 -Rev. 12=77 <br /> r <br />