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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: 1 1601 E: Hazel ton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: {209) . 466-6781 <br /> = ° -- - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/p_ -7 <br /> This Permit Expires 1 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 herein described.: This application is made in compliance with San" <br /> Joaquin County Ordinance,' ado. .1862 and the .Rul. es and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS o ue 0AI&4VT ,/TOWN 5 h*<- M2 <br /> Owner's Name _ Phonef -. 3 :!1: <br /> Address 5 - 'Qr /�/ '' Rdn�?- ,, Ci.:tyT. Tcc,r7t),✓ <br /> Contractor' s Name Ve/.L:@ j2as4laaL icense# Phone <br /> IS CERTIFICATE OF' WOR A'N'S� COMFENSATIO"1 TIN URANCE ON FILE WITH' SJLHD? YES NO <br /> TYPE OF WORK (Check) : �ELLWELL CHLO�RINATIDONPEN CI WELL EABANDONMENTCONDITIONn' DEOTHERTION[� - <br /> PUMP INSTALLATION C1- PUMP REPAIR❑ PLUMP REPLACEMENT <br />; DISTANCE TO NEAREST: SEPTIC TANK AloA19NER LINES 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial " Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing J <br /> 4e.-f Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 1 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor p,7 L v S�. ova <br /> ,_Type of Pump'y-ca a�,. ----= H..P. d <br />` PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> iHealth 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 person in such manner as to become subject to Workman's.Compensation <br /> laws of California. "; c <br /> I WILL CALL FOR A GROUZ INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION.' <br /> SIGNEDTITLE: , <br /> DATE: <br /> /e3 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT VoSE ONLY <br /> PHASE I <br />`APPLICATION ACCEPTED BY .9�1DATE O341 <br />'ADDITIONAL COMMENTS: aE <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br />,INSPECTION BY �n E � DATE INSPECTION BY DATE 11-,S-7a <br />,EH 1426 Rev.. . 12-77 1 /78 2M <br />