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SAN JOAQUIN. LOCAL HEALTH DISTRICT --�--� <br /> OFFICE USE: 1601 E. Hazelton Aye. , Stockton, CA 95205 Permit No. <br /> 1i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- �� <br /> This Permit Expires 1 Year From Date Issued <br /> .Complete In Triplicate t <br /> Application is hereby made to the San Joaquin Local Health District for a- permit to construct <br /> an"d/or 'i nstal l the work herei n1 descri bed. 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 Qr $` -CITY/TOWN e <br /> Owner's Name G Q nom CL Im C k I a.4 Q Phone 5"59 Z$'S3 <br /> Address D S� e <br /> /41 <br /> J�� c City /efPta - <br /> Contractor's Name Ar 1$5- License#-74SIMS' Phone_ ,355 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES � _N0__ <br /> TY-PE OF WORK (Eh-ec.k)-: -NEW- -WELL-0 ----DE-EPEN Cl-- =-RECONDITI.ON-[:]-- --DESTRUCTI-ONS- <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER W <br /> ;PUMP INSTALLATION 0 PUMP REPAIR p PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTICS#TANK SEWER 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 a Cable Tool Dia. of Well Excavation <br /> _Domestic/private, I Dri141e Dia. of Well Casft,w <br /> Dom estic%publ'Ic Driven gauge of Casing <br /> Irrigation ' Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection �i Rotary Type of Grout <br /> Disposal j Other Other'.Information <br /> Geophysical ! )Surface Sea4, Instal l ed by: <br /> PUMP I Contractor <br /> Type of� Pump _:..,., ..,...;�:-�; H.P. <br /> PUMP REPLACEMENT: M State Work Done . <br /> PQMP' REPAIR: [QState Work ,Done <br /> DESTRUCTION- 0-F--WELL.-.- .Well -D-i'amet-er: Approximate-De tPh.�;._T T <br /> � � �,✓� Describe Material ana Procedure <br /> 157 old <br /> I hereby certify that I have prepared this application and that the wor l wi be o e 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 licensedagent' s signature. certifies the following: <br /> "I certify that _in_therperfo.rmance of'-.the work-foK�whfich this-permi_t;_is issued„ I .shall <br /> not employ any person in such manner as to become subject to Workman's 'Compensation <br /> laws of California.” <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ; A ,. TITLE: ��.� DATE: <br /> t ' J. DRAW .PLOT PLN ON REVERSE SIDE <br /> ` - FOR DEPARTMENT USE ONLY <br /> PHASE. I ' • ,a I <br /> APPLICATION ACCEPTED BY / DATE /7 <br /> ADDITIONAL COMMENTS `1 <br /> PHASE"II' GROUT. INSPECTION PHASE III JINAL,INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE /d <br /> FN 1,19A Rnv 7 7_77' - . ' ' <br /> Af'-.S Q 3_3 _ 1 /7 9 '�I � <br />