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SAN JOAQUIN: LOCAL, HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: _ (209) 4.66-6781 <br /> APPLICATION. FOR WELL CONSTR'[JCTION OR PUMP PERMIT Date Issued, -g-7� ! <br /> This Permit Expires I. 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 ti <br /> and-/:or ,i,nstall the work'herein described: This application is made in compliance with San <br /> oa uin County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health ' <br /> District. <br /> EXACT STREET ADDRESS OA - CITY/TOWN <br /> Owner' s Name ' P o e�-- <br /> Address City - t 14 <br /> Contractor' s Name' License# Phone <br /> IS CERT,I,FI-CATE--OF-WOq flAt4'-S-COMPENSATI0tl ItA11 A*10E -OM FILE WITH— SJLHD?--­YES— <br /> TYPE <br /> yYES—TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTION C1 <br /> WELL CHL RINATION 0 WELL ABANDONMENT 0 . OTHER 0 <br /> PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENT Q W <br /> DISTRNCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1g0 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WEEL -2.47— PUBLIC DOMESTIC WELL <br /> INTENDED USE . �- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial r , Cable Tool Dia. of Well Excavation <br /> _ X ;Domestic/private_ = , Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .,=Rotary Type of Grout r - <br /> Disposal - Other Other Information <br /> Geophysical Surface'Seal Insta edza_ezz2 Z" <br /> PUMP INSTALLATION: Contractor -� <br /> r- Type of Pump H-.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QS'tate Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter '" Approximate Depth <br /> Describe Materia an 'Proce ure <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. shal 1 <br /> not employ any person/in 'such manner as to--become subject to WDrkman's Compensation <br /> laws of California." <br /> I -WILL CALL FOR A OUT INSPEC ION IOR TO GROUTING 'AND A FI AL INSPECTION. <br /> SIGNED J TITLE-' DATE: A-)-7/4 47 <br /> (-DRAW Pg?=L N ON REVERSE ID <br /> _ FOR DEPARTMENT :USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ✓��T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY "�n� DATE Z- -� INSPECTION BY DATE/�/_Jt•�1 <br /> "!-7 0 `31A <br />