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SAN JOAQU'IN IOCAL HEALTH DISTRICT FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �g Teleph9ne: (209) 466-6781 APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued r-,2s-�33,' This Permit Expires 1 Year From Date Issued Complete In Triplicate ' oqv—o/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This .application is made in compliance with San ,oaQui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. 3700 Se � . EXACT STREET ADDRESS /4 fZ 1v^Ft�� E -T-" 0" aeA- CITY/TOWN Owner's Name Al 46 40 ' Phone Address ` S CityT�JWV Contractor's Name 414 �Z,, Li cense# da -phone tyO; IS CERTIFICATE OF WORKMAN'S COSI NSATIO"! INSURANCE ON FILE WITH SJLHD? YES NO TYPE OF WORK (Check) : NEW WELL.❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C`3 PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing _Irrigation Gravel Pack Depth of Grout Seal Cathodic Protection Rotary Type of Grout Disposal Other Other Information Geophysical Surface Seal Installed by: , PUMP INSTALLATION: Contractor Type of Pump - "r�►��1 _. ...... _.�._,_ H.P. PUMP REPLACEMENT: ❑State Work Done PUMP REPAIR: WState Work Done A,,OX ` DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material an2 Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local _ Health District. Home owner or licensed agent.' s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." I WILL CALL FOR A GROUT INSPEQJ_ION,0,,PR10Z71O GROUTING AND A FINAL INSPECTION. 5IGNE , � x I TLE: DATE: R W PLOT PLIAN ON REVERSE SIDE FOR DEPAR TME T USE ONLY PHASE i APPLICATION ACCEPTED BY /(�/, DATE ADDITIONAL COMMENTS : PHASE II GROUT INSPECTION PHA ;K F4W INSPECTION INSPECTION BY DATE INSPECTION B DATE !S-- 1426 S=].426 Revue_12-77 1/78 2M ';