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NkA LOCAL HEALTY, DISTRICT <br /> �- Stockton, CA 95205 Permit No. <br /> � !�QP OFFICE USE: f 160 E. Hazel tan Ave. , . <br /> Telephone: (209) 466-6781 <br /> •,% Date Issued. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 1 <br /> (Complete In Triplicate) . <br /> � Local Health District for a permit to cotlstruct <br /> Application is hereby made to the San Joaquin . <br /> and/or instal'. the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> k. 1 <br /> CITY%TOWNOwner' s Name QiZ (��" P C Phone3� 7 <br /> Address �V �� City d C <br /> Contractor' s Name J" <br /> LiCnse� " © 41s ff Phone � <br /> I IS' CERTIFICATE-Dr-1JOI?K'SATl'S"COF,PENlcATIO"!"I"ISURA"fCE-0Pl FILE-�WITH'SJLHD? <br /> f TYPE OF WORK (Check) : �` NEW WELLI DEEPEN i7 RECONDITION N DESTRUCTION[] t <br /> ...aor <br /> WALL CHLORINATION 0 WELL ABANDONMENT a OTHER [J � <br /> PUMA INSTALLATION Q si UMP REPAIR0 PUMPA RE-P�LACEMENT-0 = <br /> ... a <br /> TANK L SEWER LINES I SPIT PRIVY-- <br /> DISTANCE TO NEAREST: SEPTICI , <br /> ; '° SEWAGE DlSi DSAL FIELOI' CESSPOOL/SEEPAGE. PIT OTHER <br /> t PROPERTY DINE - PRIVATE DOMESTI;G WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE �YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br /> k' Domestic/[ D.ri led D�, a. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> ;G.raavel Pack Dept of Grout Seal <br /> Cathodic Protec l on Rotary Type of Grout V . <br /> Disposal Oilier other'Ihfo mation <br /> _ Geophysical '►- ', Surface�Seal Installed by:% rtt Fd _ <br /> ! a <br /> PUMP INSTALLATIONS Contrac`to.rt ar <br /> Type of dump `* JU <br /> a PUMP REPLACEMENT: State Work Dane_ '�� 1 <br /> PUMP REPAIR: COState Woxk Done_ t <br /> �— k� ,� "' Approximate Depth <br /> DESTRUCTION OF WELL . Well Diameter . - <br /> -- — Describe Material and Procedure -- <br /> t k <br /> I hereby certify that �I' have prepared this application and that the work will be done. in accord( <br /> with San Joaquin County Ordinances , State Laws , and�Rulesy-and„Regulations of the San Joaquin Loi <br /> Health District. Home towner or licensed agent' sXsignature-ce:r ifies thekfollowing: <br /> "T certify; that irk the r 1! performance of the work ,for which thfs,permit iskissued, I shall <br /> not employ any person i n such manner as to b come sfiu.bj�ecio Workman' s Compensation <br /> 'laws of California 'j <br /> I WILL GALL FOR A GROUT °1 SPECTION PRIOR TO .GROU:II�iG AN�Dy A FINAL INSPECTION. <br /> SIGNE ' TITLE: CV / l' DATES-`3� �" -7 <br /> DR W PL T PL N-ON- REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �r`' R DATE 3 0 Z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS :1. I I <br /> PHASE II GRO��'-T INSPECTION PHASE III FINAL INSPECTION .. <br /> INSPEC?IDN 8Y ! DATE 11 <br /> E-�19. % INSPECTION BY DATE - <br /> 2 <br /> LH 14 26 Rev. <br />