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SAN JOAQ <br /> /1601 <br /> UJN 1.t AL HEALTH DISTRICT <br /> FFICE USE: t E. Hazelton AVe. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) ' 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/t9 -,7/- 1r <br /> This-.Permit Ex ices ,l. Year From Date Issued <br /> I� 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. Thies application is made in compliance with San .. <br /> Uoanuin County Ordinance,! No. 1862 and, the Rules and Regulations- of the :San Joaquin Local. Health <br /> District. II <br /> EXACT STREET ADDRESS CITY/TOWN �/ � 1s <br /> Owner's Name v r y` ' �� ` �t r <br /> Phone <br /> Address... .. 6 erCIK pie; v'xr - ... city � a <br /> Contractor's Name LzkjL nr'"ih,GLicense# Phone 3 Cc <br /> IS CERT-I-PKAT-.E--0°FWORKMAt4''-S-�c.omPEldSATIO"a I,aSURA"lCf"OPa FILE' 111'" `SJLf1D? Y£S <br /> i <br /> TYPE JOF_WORK (Check): NEW WELL'C54, DEEPEN ❑ RECONDITION DESTRUCTTON`[j—`" <br /> WELL CHLORINATION Q ❑ OTHER ❑ _ <br /> PUMP INSTALLATION fi4rz, PUMP"REPAIR"❑ PUMP REPLACEMENT ❑ � ! <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK_516f1- SEWER LINES '7-r`4 PIT PRIVY <br /> ` ,.SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT 'OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE �� TYPE OF WELL <br /> I, CONSTRUCTION SPECIFICATIONS <br /> Industrial -..Gable Tool Dia:�,of Well Excavation /2- � <br /> (Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of' Casi`ng <br /> Irrigation Gravel Pack Depth of Grout Seal cr.0 -XI-211- <br /> Cathodic Protection Rotary Type of Grout gi✓`T' <br /> Disposal I Other ` , Other Information } <br /> Geophysical Surface Seal Installed b : /L♦ L1.� <br /> PUMP INSTALLATION: Contractor ,,E� ` JE i-c ,�� A4 N S,CXk-iC , <br /> Type of Pump �.Mo YWi� ,°P. • ,_ <br /> PUMP REPLACEMENT: Q State Work Done E � • . <br /> PUMP REPAIR: Listate Work Done i <br /> DESTRIJGTION-OF�WEL±-: Well Diameter = - AProximate- Dept?i <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that theiwork will be done in accordance <br /> Mith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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 perso0 in such manner as to become subject toWorkman 's Compensation <br /> laws of California. 11 J <br /> E WILL CALL FOR A GROUT INSPECTION . PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED <br /> TITLE: — DATE: <br /> DR W PLOT PL N ON REVERSE IDE <br />'HAS E I' <br /> I! FOR D PARTMENT USE ONLY <br />,PPLICATION ACCEPTED BY 1 DATE__L0Z11-21P_ <br />,DDITIONAL COMMENTS : 4 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE <br /> `��' INSPECTION BY DATE . ` <br /> H 1426 Rev. .`12-77. :�i , 7Q nM <br />