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SAN "JOAQUIN LOCAL -HEALTH DISTRICT <br /> OFFICE.-USE: 1601 E. Hazelton,. Ave. , Stockton, CA 95205 Permit No.7 91-r, c.1 2 t <br /> Telephomq-,;'v(,209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,Z2 <br /> (,Complete In Tripl"icate). <br /> Application is hereby made to'the San Joaquin Local Health" District fora" permit to construct <br /> sand/or install the work herein, described. This application. is ,made, in compliance with San ' <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the� San Joaquin Local "Health <br /> District. <br /> EXACT STREET ADDRESS tvl-c & E ��kT,Y��WN <br /> Owner's Name 1 phone to ~ <br /> AddressCity .Cc�.a/a,,, <br /> • `-'�� <br /> Contractor's Name I , . Li censet��S?1/y Phone j? <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN, RECONDITION DESTRUCTION <br /> CHLORINATION 0 WELL ABANDONMENT 0 OTHER F-3 <br /> a PUMP INSTALLATION 0 PUMP REPAIR E3 PUMP REPLACEMENT [ f <br /> DISTANCE TO NEAREST: SEPTIC TANK T <br /> �_�.� SEWER LINE . ,o., ` . .PIT PRIVY --- <br /> SEWAGE": 'DISPOSAL FIELD/oo !4 CESSP OL/SEEPAGE IIT — OTHER -. <br /> PROPERTY LINVAPRIVATE DOMESTIC WELL .C� : PUBLIC DOMESTIC WELL __-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � _Cable Tool Dia. of We Excavation .14 <br /> Domestic/private t Drilled Dia. of Well Casin <br />—Domestic/public iA Driven Gauge of Casing. /^. ;1.4 / <br /> - „�(.Irrigation ► Gravel Pack Depth of Grout -Se-a-7—rd- <br />,Cathodic Protection A Rotary Type of Grout <br /> Qisposal I Other -Other "Information <br />____::Geophysical <br /> ' Surface Seal Installed by._ __ <br /> pUMPJNSTALLATION: Contractor " <br /> Type of-jPump W. H.P. f <br />?UMP REPLACEMENT: . Q Stat-6'Work Done <br /> SUMP REPAIR: `I h <br /> e Work Done ° <br /> ❑Stat , <br />]ESTRUCTION" OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> pith San Joaquin County Ordinances , State Laws, and. Rules and Regulations of the San, Joaqui-n "Local <br /> lealth '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 asito become subject to Workman's Compensation <br /> laws of California. s <br />' WILL=CALL-.FORAUTINSP ON PRIOR TO .GROUTING`.AND A'FINAL INSPECTION. 4 s <br /> SIGNEDTITLE: DATE: <br /> D PL L - <br /> ON REVERS DE <br /> i FOR DEPARTMENT USE ONLY <br /> CHASE I <br /> APPLICATION ACCEPTED B l DATE <br /> ADDITIONAL COMMENTS: t <br /> -- <br /> PHASF I GROUT IN5PEGTION 4 - PHASE III FINAL INSPECTION ._ <br /> NSPECTION DATE INSPECT BY DATE ~� <br /> 1 -- <br /> H 14 26 Rev: 9/ r - 1 <br /> 78 2M <br />