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co ten.iom4 ' h SAN JOAQUIN LOCAL HEALTH O1S I RIC 1 <br /> OFFIICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.zr__ <br /> Telephone: (209) 466-6781 <br /> y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /3-/8-7R <br /> ' Thik Permit .Ex ires 1 Year From Date Issued <br /> Comphete In Triplicate <br /> oplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'd/or' install the work herein described. This application is made. in compliance with San <br /> aquin County' Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> istrict. ("/.Q.tlrg E- ioga6/�'4cco •49 ,."T �4pnJ • (cS-��o Gz3 <br /> 'ACT STREET ADDRESS a/7 29 .L�`I g ,?Aac 1i A,4/n 1' 7a•1• 0 CITY/TOWN . <br /> ��� <br /> Nner's Name ,�/sic ✓ S'as�aidze Ate", <br /> _ Phone <br /> �dress c Ig lr%,g .r City d' _— <br /> ntractor's Name 4@License# M3 7k_CThone. eo4 y -Z676 <br /> wE CERTIFICATE OF WORKMAN'S COMP SATION INSURANCE ON FILE WITH SJLHD? YES - NO <br /> PE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION © DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> tPUMP INSTALLATION p PUMP, REPAIRIKI PUMP REPLACEMENT ❑ o <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY °4 ' <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVA E DO ESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia. of Well Excavation d <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 y: <br /> MP INSTALLATION: Contractor--' <br /> Type of Pump ^Tu r H• _ _* 7•l <br /> UMP REPLACEMENT: ❑State Work Done <br /> UMP.`REPAIR: ®State Work Donees <br /> =ESTRUCTION OF WELL: Well Diameter Approximate Depth..',,:. <br /> ■r Describe Materiaan rote Fure <br /> hereby ,certify that I have prepared this application and that the work will be done in accordant <br /> tth San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> alth 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING F NSPECT N. . <br /> 'SIGNED TITLE: ATE: 41 Y <br /> RAW PLOT N ON <br /> FOR DEP RTMENT ONLY <br /> UHI DATE .2 /7 <br /> � <br /> TION ACCEPTED BY - - <br /> �DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE EI -FLNAL INSPECTION <br /> tNSPECTION BY DATE. INSPECTION BY DATE_3-)'(—)S <br /> - - i - - -1/,78 2M - <br />