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n �le SAN JOAQUIN LOCAL,HEALTH DISTRICT - <br /> FF CE USE: 1601 E.—Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 4,66-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date Issued !2;--1 7 7 <br /> This -Permit Ex fres 1"Year From Date Issued <br /> P� Complete In Triplicate <br /> Application is h,ereby ,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 Rules and Regulations -of the San Joaquin,Local Health <br /> District. l�'f- 170C-) <br /> EXACT STREET ADDRESS ;Ct. �'� �� �� Soso ; o Y/TOWN <br />.Owner's' Name ,��� � a�a.i.� e� Phone <br /> Address _ _ i � c� U3l�t..�. City . ._ <br /> Contras <br /> tor' s Name � License# l8.3 7sd-7hone <br /> IS CERTIFICATE OF WORKMAN'S CO ENSATIO'f INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE' OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ i <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC jTANK , SEWER LINES PIT PRIVY <br /> SEWAGE.'DISPOSAL' FI£LD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . (,1 ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .,Cable Tool Dia. of Well Excavation '1 <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal �Other Other Information : <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 1"'r_ <br /> Type of Pump k✓ l�= -r H.P. jor,6 <br /> PUMP, REPLACEMENT: [] State Work Done <br />�&KLPP REPAIR: M State Work Donedltz, 3,0 <br /> DESTRUCTION OF WELL: Well Diameter <br /> xk Approximate Depth <br /> Describe Materia 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 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 subject to Workman 's Compensation <br /> " laws of California." <br /> I WILL CALL FOR A GROUT INSPEC P R GROUTING AND A FJ4L INSPECTION. <br /> SIGNED ' 1E: DATE: dj�� <br /> <� W L PL N REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED. BY_ DATE <br /> ADDITIONAL COMMENTS: :��� ,. .. . <br /> PHASE IT, G OUT INSPECTION PHASE- II-I. -FINAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE S <br /> FIS 149r, Rau 19-77 '1/78 2M.A4 <br />