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ti - <br /> 4 V/ SAN- JOAQUIN LOCAL, HEALTH DISTRICT <br /> QFFIC£ USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2Z3 <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued ;7-7/ <br /> This Permit Ex i.re.sal .Year From Date Issued <br /> .Complete In Triplicate)' <br /> Application is hereby made toAhe San Joaquin Local Health District for a permit to construct <br /> and/or ,install the work herein`. des-cribed. This application is made in with San . <br /> Joanuin County' Crdinance No. 1862 and the Rules and Regulations of the.. San Joaquin Local Health <br /> district. <br /> EXACT STREET ADDRESS e_an CITY/TOWN <br /> Owner' s Name -rd Phone T r <br /> Address - - NQ . 7� <br /> Li cease# 13 - - 'hone C -x, 6 � <br /> Contractor' s Name .� '" _? i <br /> y <br /> IS CERTIFICATE OF WORKMAN'S CO'MPEN TIN INSURANCE ON FILE WITH SJLHD? YES=e&= NO <br /> TYPE OF WORK (Check) : NEW WELIL❑ DEE PEN-0 'RECONDITION C] DESTRUCTION[] <br /> WELL CHLORINATION C3 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR(4 PUMP REPLACEMENT <br /> A � <br /> DISTANCE TO NEAREST: SEPTIC: TANK SEWER11NES PIT PRIVY <br /> SEWAGE]DISPOSAL FIELD " CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ ,e <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool -r -Dia: -of Well—Excavation � <br /> � X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publ c- 1 Driven Gauge of Casing 7 <br /> Irrigation, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Dispo-sal ""f Other Other 'Information <br /> Geophysical S/urface :Seal Installedby: <br /> : <br /> PUMP INSTALLATION: Contractor—,,.-( - <br /> Type of Pump H.P. <br /> ' <br /> PUMP REPLACEMENT: ❑State Work Done <br />, PUMP REPAIR: (-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material .and Procedure <br /> I hereby certify that I ha've ,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 fol-lowing:, -. <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 /> I " laws of California. " I <br /> FI WILL CALL FOR A GROUT INSPECTION PRIOg TO-G OUTING AND A 'FINAL INSPECTION: <br /> SIGNED DATE:' <br /> DRAW P O PLAN ON U ERSE SIDE)_1 <br /> FOR DEPARTMENT USE ONLY <br />`.PHASE I ` <br /> APPLICATION''ACCEPTED B.Y140� <br /> DATE 7//0 /17-P" <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />�-INSPECTION BY �, , DATE INSPECTION BY ` DATE <br />`�u l n OC 0_77 -. ��.d.— ^-� 'C-A, 1./7.'8` <br />