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• FFICE USE: SAN JUAQU;.^1 LUCAL HEALIH Uls[RIC! <br /> 1 E. Hazelton Ave. , Stockton, CA (, ,5 Permi-; No.z - 2,11.3 i <br /> Teleohone: (209) 465-6781 <br /> --1 FOR WELL CONSTRIirTION OR PUMP PERMIT Date Issued,/J--33?-2A- <br /> APPLICATION <br /> This, Permit �,!_es 1 Year From Date Issued <br /> owpIE.te In Tr7'ITate <br /> Application is hereby made to the San Jot,cuin Local Health District for a perrait to construct <br /> and/or install the work herein describec. This application is made in compliance with San <br /> .'oanui n County Ordinance "o. 1862 and the ,:ales and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADPRESS 7� �� 'C��t�dl � CIT'!/TOWN<-`i <br /> � �C7- -7 <br /> . Owner's Name-���LV _ V y'LL!�a _ Z-, C, Phcne__ <br /> Address Ci ty_ <br /> t Contractor's Name1�`17�,��G(�C (.i u<<� License#�� Phone <br /> IS CERTIFICATE OF WORKt'AN'S COMPENSATIM! INSUR '!CE OI! FILE WITH SJLHD? YES l/ NO <br /> E TYPEOF WORK (Check) NEW WELL DEEPEN Cl RECONDITION ❑ DESTRI,CTI'ON❑ �d <br /> ! WELL CHLORINATION ❑ WELL ABANDONMENT O OTH-R11 <br /> PUMP 1NSTALLATION [Zi--�UMP REPAIR❑ PUMP REFLAC':MENT ❑ 40 <br /> DISTANCE TO NEAREST: SEPTIC TANK�'' C -SFWE.< LINES IT PRIVY <br /> SEWAGE DISPUS .FIELD CSS/SEEPAGE F7 �fOf ER v <br /> PROPERTY LINEk-.'fPRIVATE DOMESTIC WELL --- P11BLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF 14ELL CONSTRUCTION SPECIFICATION" <br /> Industrial _ Cade Tool Dia. of Weil Excavation / jiz <br /> omestic/private y'_t7riIIed Dia. of Well Casing `1-.c-6. <br /> k---Domestic/public Driven Gauge of Casing_ ` s_:1C_ <br /> Irrigation ravel Pack Depth of Group. Sea !Z <br /> Cathodic Protection Rotary Type P'--G.-out <br /> Disposal Other _ Other'iifformation <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump sir.. H-P - _ <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTJON OF WELL: Well Diameter Approximate Depth _ <br /> t®� f C,.,�eDeicribe <br /> Material an-Procedure <br /> _l �-,'� � <br /> I hereby certify that I h2(ve prepared this application .end 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 signatur! certifies the following: <br /> "I certify that in the performance of the work for whim this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Cumpensation <br /> laws of California." <br /> I WILL CALL FOR A 'ROUT INSPECTION PRIOR TO GROUTING AND AA FINAL INSPECT ON. <br /> SIGNEDD -x/-'CV 1 4- — TITLE: !C ✓ 7 _ DATE: <br /> _ DRAW -NL T L N ON REr/E(2S SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D // <br /> PLICATION ACCEPTED BY cls 4{t� �_ DATE // <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P!!ASE III FINAL INSPECTION <br /> INSPECTION BY� _ DATE \Z y � INSPECTION BY �'�^ DATES _ <br /> EH 1426 Rev. 12-77 1!/78 2M <br /> Aid <br />