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1,,,1N JUFdIUn LOCAL HEALIH UIJIRILI — —.—� <br /> FFICE USE: <br /> 301 E. Hazelton �1%e. , Stockton, CA ?05 Permit No.7y,-/Z,,1.3 <br /> • Teleplior,e.: (209) 466-6781 <br /> —+ APPLICA"ION FOR WEi_!_CONSTRU 'TION OR PUMP PERMIT Date Issued/%�a9�� <br /> This Permit Exnioes 1 Year From Date Issued <br /> —pomp ate Tn TrioT7ate <br /> Application is h-reby m-c `n the San loo:rl" local Health District for * 'a construct <br /> and/or install -he woo, h­-e'.n descr i. -i hi s app i i cati on is made in ,.o ,r-; with San <br /> �'oao::in County erdinancc ';u. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET A RESS �r��i' , cl'II`��}] ' CIT`:/TOWNr 'd�/_�ff)'7 <br /> Owner's Name "'jF �'' _r�} ��fZ — N Phcne_ <br /> Address _ /,/ Ci ty�_ <br /> Contractor's Name ~�`'� '�?-u,L .� r� License#�� Pi;one 'f/-�Z f <br /> IS CERTIFICATE OF WORKr,AN'S COMPENSATION INSUR. "!tl FILE WITH SJL'iD? YES �� C <br /> TYPE OF WORK (Check) : NEW WELL ?' DEEPEN CJ RECONDITION ❑ GESTRI,CTION❑ W <br /> WELL CHLORINATION ❑ IJELL ABANDONMENT 0 OTIIcR Iw] <br /> PUMP INSTALLATION [Zj--fUMP REPAIR 0 PUMP REFLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANKffPC SEWER LINES 7hPIT PRIVY <br /> SEWAGE DISPUS—g,FIELD- C SSPOOL/SEEPAGEPIT ,SfICRWELL 0 <br /> — PROPERTY LINFJkSS RIVA"i E DOMESTIC ,JELL =� <br /> r ,3LIl, U0 E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI-ONr <br /> Industria' Cale Toil Dia. of Well Excavationi�� <br /> q D mestic/private _Z7 rilled Dia. of We'11 Cis•ing <br /> _ mestic/public Driven - Gauge of Casing� `e_:Z k f2 ell <br /> Irrigation �.�(ravel Pack Depth of Crout Sea - <br /> Cathodi, Protection otary Type c'- •out s <br /> Disposal Other_ Otner 'iiiformaLi on (� <br /> Geophysical Surface Seal_Installle-d by: i Q <br /> PUMP INSTALLATION: Contractor /,r Y`rl, is ,� .' rl�-• <br /> Type of Pumper//:lLf , <br /> PUMP REPLACEMENT: ❑State Work Done <br /> ` PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> De cri be Material and Procedure--------- <br /> I <br /> roce ure --___I hereby certify that I hive prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules arid Regulations of the San Joaquin Local <br /> Healtn 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 sutject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FORA R U; INSPECTION PRIOR TO GROUTING AND A FTNALIIJSPECT ON. <br /> SIGNED ��' C' c l- - TITLE:���� �? _ DATE: <br /> (DRAW PLT PLA ON REVE-,SK E <br /> FOR DEPARTMENT USE. G_."il_Y <br /> PHASE I <br /> PPLICATION ACCEPTED 4Y-�� � —._. - DATE_ // -1 _ <br /> zQ <br /> ADDITIONAL COMMENTS: <br /> PHASE" II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY LkA DATE \Z i� INSPECTION BY DATE 2 <br /> EH 1426 Rev. 12-77 l.!/78 2M <br /> 4 <br /> _ 4Ah1'�`P► R�itI�AOA�!AAt�rrii�« �+►"�"tw+':.�� 1e�'I�/�aTr, ,:: . <br />