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SAN JOAQUIN LOCAL HEALTH UiS I-kIC I <br /> > ICE USE: 1601 E. Hazelton Ave.., •Stockton, CA 95205 Permit No.� Y <br /> I Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> I is, Permit4Expires 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 <br /> and/or install_ the work here described. , This application is made. in compliance with San <br /> tp� doanui n County Ordinance No., '1862 and the Rules .and Regulations of the San Joaquin Local- Health <br /> ! District. 13.5-dK )n Cd�/b <br /> EXACT°STREET ADDRESS N .. ,,. �"' "� CITY/TOWN <br /> r� <br /> Owner's Name ,L 4r-A, Af, <br /> Phone <br /> Address g' ! / .IsJ C i tY . <br /> Contractor's Name ,�""" ,� License# <br /> &CPhoneYQ; 7-,!� <br /> IS CERTIFICATE OF WORKf1Atd'S COMPE TION IisSURA^JCE ON FILE WITH SJLHD? YES NO <br /> TYPE OFWORK (Check) : NEW WELL � w. d. <br /> WELL CHLORRINATIONPO� WELL EABANDONMENT DESTRUCTION <br /> 0 [) <br /> PUMP. I NSTALLATI ON W PUMP REPAIR 0 PUMP REPLACEMENT [ r <br /> DISTANCE TO NEAREST: SEPTIC: TANK SEWER LINES PIT PRIVY <br /> SEWRGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Ind <br /> ustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven A Gauge of Casing <br /> Irrigation e Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j) Rotary T, pe,of Grout ' <br /> Disposal F Other Other Information <br /> Geophysical (.f Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> A, Type*'of( pump <br /> [a H.P. G <br /> PUMP T; R <br /> �Sta ie Work Dane' . <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describematerial and Procedure Approximate Depth <br /> I hereby certify that I havere ared this'P p 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 /> fI certify that in. the performance of the work for which this permit is issued, I shall s <br /> not employ P y an y person in such manner as to become subject to Workman 's Compensation t <br /> laws of California. " I <br /> I WILL CALL FOR A GROUT INSP I P I T GROUTING AND A FINAL INSPECTION: <br /> SIGNED : �} <br /> TLE: i�'r-,�,/' DATE: <br /> 'RAW PLOT PL ON REVERSE SIDE <br /> 1HASE I r R DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y DATE <br /> kDDITIONAL COMMENTS: ! 01 <br /> i <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BYDATE INSPECTION BY TATE_?- (, /t/ <br /> ; <br /> H 1426 - Rev, 12=77 0 <br />