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s <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave..,. Stockton, CA 95205 Permit No.' _ - <br /> �. Telephone: (209) 4.66 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 .Year -From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made, to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This,application is' made in compliance with .San <br /> Joaquin County Ordinance No. 1862 and the Rul:es .and Regulations of ,the San. Joaquin Local Health <br /> DistrictS,Y: cr—Tv . <br /> EXACT STREET ADDRESS � AV, 1 _A� WY/TOWN <br /> Owner's Name Z9a Phone_ <br /> Address City o ` SS <br />( Contractor' s Name d241Z � Licens Phone 2TIA <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION THS RANCE ON FILE WITH SJLHD? YES NO <br /> s <br /> TYPE OF WORK (Check) : NEW WELL Ci DEEPEN ( RECONDITION Q DESTRUCTION C3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC( TAN - SEWER LINES,Sp �{ PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PI — OTHER <br /> PROPERTY LINOP PRIVATE DOMESTIC WELL,— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casinga &AWWZ <A <br /> X_Ir..ra_gat on'_-, Gravel Pack Depth of Grout ea1__ <br /> Cathodic- Protection t. Rotary Type of Grout <br /> Disposa•1 i - Other Other Information <br /> Geophysical'. Surface Seal Installed <br /> I PUMP INSTALLATION: Contractor <br /> Type of -Pump H.P. <br />' PUMP REPLACEMENT: [] State 'Work Done <br /> PUMP REPAIR: 0 s to e Work Done <br />` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 1, 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 subject to Workman's Compensation <br /> laws of California." <br /> qI WILL CALL FOR A GROUT IN ECT !V R TO GROUTING ANDA FINAL INSPECTION. <br />. SIGNED TITLE: r DATE: <br /> PLOT PLAIT ON REVER SIDE V <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL" COMMENTS: !I <br /> PHASE II, GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY & q DATE 9-x' -7 P <br /> �Fu 7d99 oo„ 1177 Y .1/78 2M <br />