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SAN JUAQUlN .LUCAL (1tAL I H UIS I RIL I <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, <br /> CA 95205 Permit No. <br /> Telephone; (209) 466-6781 <br /> Date Issued-5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex i res •1 .Year From Date Issued <br /> r� Complete In Triplicate <br /> Application is hereby made to the San Joaquin' Local Health Distri-c.t for permit to construct <br /> and/or install the work Herein described. This applicatioh-A s made in compliance with San , -, * <br /> Uoan.:Tn County Ordinance °Yo. 1B62 and the RulesandRegulati she San Joaquin Local Health <br /> Gtistr�ct. J <br /> EXACT STREET ADDRESS. # . ap,e v � 1CITY/TOWN <br /> Owner's Name r �, e,j -e, w` Phone <br /> Address C'`fozr P, Per—,,,L.•.K9 city <br /> Contractor's Name 0— {eai cense#3 6 71.6 Phone 'S <br /> i TS CERTIFICATE OF W01ZKt1AN'1, CO"• ENSATIOPt INSURANCE ON FILE WITH SJLHD? YES <br /> ITYPE' OF WORK (Check) : NEW WELL ML DEEPEN Q RECONDITION ❑ DESTRUCTIONF71 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q •OTHER O <br /> PUMP INSTALLATION p PUMP REPAIR: _- -PUMP ,REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1oa SEWER LINES'-16e PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. :PRTVATE DOMESTIC WELL PUBLIC DOMESTIC LL tN <br /> INTENDED USE `..TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well -Excavation I ' <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> I Irrigation _ ��Gravel Pack r: Depth of Grout Sea <br /> Cathodic Protection Rotary " Type of Grout <br /> Disposal Other :A Other Information <br /> Geophysical __-� :,, - Surface Seal Installed y:CE z 1• cu �k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.-__ <br /> I.PUMP REPLACEMENT: r]State Work Done <br /> PUMP REPAIR: p State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> =:rt Describe Material and Procedure <br /> 'T <br /> !I hereby,_ certify that 1 have prepared this application. and that the work will be done -in accordanc+ <br /> wr.th"'Se Joaquin County Ordinances, State Laws, and Rules and Regulations of the Sari Joaquin Local <br /> Hea-lt+ 'District. Home owner or 1-icensed,-agent's.-si.gnat-ire certifies -the-fo11•owirrg:v" -• <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 /> iI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. �� . <br /> SIGNED TITLE: DATE: <br /> DR R.,.;P L-07715AW ON REVERSE- SIDE3 . <br /> ONLY <br /> F .RaDEP RTMENT USE•s ; <br /> iPHASE I � <br /> LICATION ACCEPTED` BYAde :%AWZ Asor_ SZ .DATE <br /> nuOITi;ONAL COMMENTS: '` <br /> PHASE II OUT ,INSPECTION �' PHASE II•I FINAL INSPECTION <br /> 'INSPECTION BY DATE 7;7-8-79 INSPECTION*BY• DATE <br /> JEH 1426 Rev. 12-77 <br />