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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> AOR FFICE USE: 1601 E. Hazelton Ave. , Stockton,- CA 95205 Permit No. <br /> Telephone: (209) 466.,;.6781 : -, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> (t—oi <br /> nplete In Triplicate)"" <br /> Application is hereby made to kthe San Joaquin Local Health District 'for apermit--to construct <br /> and/or install the work herein,: described. This -application is made,in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Ru les and -Regulations of the San Joaquin Local Health <br /> District. <br /> -- rs cz f <br /> EXACT STREET- ADDRESS 3 C S S' IV. � "I� W `� '' CITY/TOWN / G k M. <br /> � <br /> Owner's Name M D&4 Phone R G - / 7 a 6 <br /> Addressc.City . _cam <br /> Contractor's Name I&P uL.0 <br /> LL pn ,`L1/a�GLi cense#3��? --- - °.Phone -3 4,� " /b 8 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? I'YES 0 � <br /> TYPE OF WORK (Check) : NEW WELL', DEEPEN a RECONDITION [:] DESTRUCTION 1�4 <br /> WELL CHLORINATION E3 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION PUMP .REPAIR❑ PUMP REPLACEMENT Ca - <br /> DISTANCE TO NEAREST: SEPTIC TANK/A4 r SE ER LINES�p6�... . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 41VA19 CESSPOOL/SEEPAGE PI���' OTHER <br /> Coo -F--(-PROPERTY LINE - PRIVATE DOMESTIC WELL�2 PUBLIC DOMESTIC WELL g- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION- SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WeT1 Excavation Z2Domestic/private i Drilled Dia. of Well Casing <br /> F Domestic/public A Driven Gauge of Casing_ , <br /> Irrigation I Grave] Pack Depth of Grout Sea 65� <br /> Cathodic Protection ii Rotary Type of Grout ,' h 'T' <br /> Disposal Other Other Information L. <br /> Geophysical SurfacerSealTInsta ed b L K. <br /> _ �' �. <br /> PUMP INSTALLATION: Contractor kLo v ic�i l�L n,4 -��'%y J� -se t2 V' <br /> Type of Pump ,� r" �-- _ H.P. Z �4, N•`e <br /> PUMP REPLACEMENT: a State Work Done <br /> PUMP REPAIR: ' ❑State Work Done' - <br /> DESTRUCTION <br /> one`"DESTRUCTION OF WELL: Well Diameter Approximate Depth w <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that I have prepared this application and thIat, the w6-W will be done in accordance <br /> with San ,Joaquin County Ordinances,j,State Laws, and Rules, and.,Regulations of the-San Joaquih -Local <br /> Health 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 f <br /> T not employ any person in such manner as to become subject to Workman's. Compensation # r <br /> f I <br /> Taws of California. <br /> I WILL CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. 1 <br /> SIGNEDTITLE: D- ---� DATE: /.2 <br /> a T <br /> (DRAW PEOr7LW ON REVERSE SIDE - -- <br /> -' - - <br /> FOR-DEPARTMENT,USE ONL_Y� f. <br /> PHASE I <br /> APPLICATION ACCEPTED DATE /,2Z,72 1174� <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY_ rAl DATE 'ay INSPECTION BY DATE <br /> EH 14 26 Rev. 9/7$ _ /78 2M' <br />