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SAN JOAQUIN ;LdCAL-HEALTH DISTRICT <br /> F�"_QFFICE USE: 1 1601 E. HazeltonAAve.1, Stockton, CA 95205 Permit No. _/36 9 <br /> Telephone:,,: (209) 466-.6781 <br /> APPLICATION FOR_WELLwCONST:RUCTIONNOR PUMP PERMIT Date Issued /,/r}'8' <br /> This..Permit= Expire t 1:.Year.`Froi Date Issue . , <br /> Complete In' Triplicite <br /> Application is hereby made to the San Joaquin : Local Health .Distri,ct -for a perm-it.to construct � I " <br /> and/or i nsta11 the work he.rei n descri bed.. .Thi s;' appl ication, i s made ;i n .compl i ance w°i th :San <br /> Joaquin County,2Ordinance! No. . 1862 and the Rules :and; Regulations .of the. San Joaquin,,Local Healt <br /> Distri ct.1` S'7s1 -vV- vE pe-d <br /> EXACT 'STRE�T ADDRESS' & TTY/70WN <br /> Owner's Name <br /> Phone <br /> Address Gity_ f' <br /> w <br /> Contractor's Name License Phoney-�,�jl} <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO"d INSU ANCE ON FILE WITH SJLHD? YES <br /> No <br /> 'TYPE OF WORK (Check) : NEW WELL 0 DEEPEN [#___ _RECONDITION C] DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTAI:CATION [] PUMP REPAIR❑ PUMP REPLACEMENT ❑ ('6 to <br /> DISTANCE TO NEAREST: SEPTIC TANK + SEWER LINES ` PIT PRIVY <br /> SEWAGE DISP L IELD 7 CESSPQOIL/SEEPAGE PIT ._. OTHER <br /> PROPERTY LINE/ .�'RIVA —DOMESTIC WELL ZZlt PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cif <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled `. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casin <br /> Irrigation V _Gravel Pack Depth-of Grout.Sea + <br /> Cathodic ProtectionRotary Type •f' Grout �Y � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP' REPAIR: ❑State Work Done F <br /> DESTRUCTION OF WELL: Well Diameter �Ap'proximate ue—:p�`- <br /> Describe Material an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> . '.I _certi.fy .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. " , ..r - _ <br /> I WILL CAL OR A GR SP T N PRIOR TO GROUTING AND A FINAL INSPECTION. F <br /> SIGNED TITLE: ° 'DATE: ,srJ� <br /> (URAW PLOT PL N ON REVER IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 / j <br /> PPA- LICATION ACCEPTEDBY ,f;®,rDATE //-2-/7 �f <br /> ADDITIONAL COMMENTS: 2aa� dift - <br /> PHASE 11 URUUIINS C I-ON PHASE III FINAL INSPECTION <br /> INSPECTION. BY DATE INSPECTION BY C . j4jn09n1A,,DATE an 7 ; <br />;H 1426 Rpu- 12_71 17A .. Thr <br />