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n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR 0FFICE USE: v CC <br /> 1601 E. Hazelton A,�e.-, Stockton, CA 95205 Permit No. 7y�- G <br /> Telephone: (209) 456-6]81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> j '(Eomplete' In Tri.0licatej.- <br /> Application is herebymade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work q <br /> rk 'herein described. This application is made incompliance with San <br /> Joaquin County Ordinance" No 1862 and the Rules and Regulations of the San Joaquin Local - Health <br /> :District.- <br /> I� N <br /> EXACT STREET ADDRESS "iZ i , CITY%T4WN �Ap,,, •�` <br /> Owner's Name !�Y.-1' - G� ALee - -- _ Phone — tl <br /> Address j, City <br /> Contractor's Name AM�! Li cense Phone' <br /> IS CERTIFICATE -OF WORKtiAtd'S ICO"9PENSATIot-I IN5URA"ICE ON FILE WITH SJLHD? YES . <br /> TYPE OF WORK (Check) : NEW WELLIQ DEEPEN ❑ RECONDITION [' DESTRUCTION[� - <br /> WELL �ICHLORINATION 0 WELL ABANDONMENT ® OTHER 0 <br /> PUMP J NSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT <br /> D_IST_ANCE TO NEAREST: S>EPTI!C TANK, SEWER LINE !-( PIT PRIVY — <br /> SEWAE DISPOSAL FIELD CE5L/SEEPAGE PIT OTHER <br /> PROPERTY LINF/A' RIVAT�ESTIC WELL9Q I PUBLIC DOMESTIC WELL . <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - <br /> Industrial _Cable Tool '4` "'' Dia. of Well- Excavation .-I2 )Domestic/priv-ate 1! Drilled Dia. of Well Casing_ .- u <br /> Domestic/public � � Driven. ' Gauge of Casing ! <br /> Irrigation �� Gravel.-Pack-,E„, Depth of-Grout-Se— � <br /> CathodicWed <br /> Protection Rotary Type of Grout ' ' � ��;s„�,vf:;� <br /> Disposal -Other -' ""Other Information �-- -- <br /> Geophysical � . Surface'Seal Insta ed. x <br /> PUMP INSTALLATION: Contractor'.-''� r ` <br /> ti <br /> Type jlof Pump H.P. <br /> jk <br /> PUMP REPLACEMENT: State Work Done <br /> �] o k <br /> PUMP REPAIR._:. ❑State Work �Done M <br /> DESTRUCTION OF WELL: Welliameter k} �-� Approximate Depth <br /> D <br /> Describe Materia -,-an Procedure <br /> I hereby ' <br /> y certif y that I have prepared this application and that the work wyll be done in accoo,oance <br />:with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin L'cal <br /> Health District. Home ownerior licensed agent's signat`ure-,-certifies the following: Nff <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. "I. C - <br /> I.. WILL CALL FOR A GROUT : .N C 0 PRIOR TO GROUTING AND A'FINAL' INSPECTION. <br /> SIGNED �� TITLE: DATE: <br /> PMT PLAN ON REVERS IDE)- . <br /> w i .FOR DEPARTMENT USE ON <br /> PHASE I - "T n <br /> VPPL I AATI-ON ACCEPTED BY DATE LA;)- ()Z2_2--_ <br /> 'ADDITIONAL COMMENTS: r <br /> I. PRASE IiIGROUT INSPECTION PHASE II FINAL JNSPECTION <br /> INSPECTION BY DATE ,7 Cf <br /> 7f INSPECTION BY 1,f DATE '7 <br /> / ” _2 Q 4 <br /> EH 14 26 Rev. 9 78Y , 5' �. � g./ _2M .�: <br />