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' I , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Date Issued.5 - -? <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 No.. 1862 and -the Rules and Regulations of the San Joaquin Local ' Health } <br /> wistrict. <br /> E WT STREET ADDRESS • 1 2 5_ {� 4 CITY/TOWN TRA <br /> 0 er's Name L u i s ,M A n1 1A E rn R R_i I A _--- Phone � s <br /> Ms s s E � q s 5 C i.ty 7.�2�►c�.. . - <br /> actor' s Name License# Phone E <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENSATIO�! I'NSURAIaCE ON FILE WITH SJLHD? YES I�0 <br /> TYPE- OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION E] <br /> WELL CHLORINATION Q WELL .ABANDONMENT d OTHER 0 � <br /> Ir PUMP INSTALLATION" PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing —PA <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> F Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: ,G Contractor H P. 4 <br /> Type of Pump s F — <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter x Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby 'certify that I have prepared this application and that the work will be done in accordanc, <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin 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 <br /> f not employ any person in such manner as to become 'subject to Workman 's Compensation <br /> laws of California."' <br /> II WILL C FOR A GROUT INSPECTION RRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SAED t'a, TI.TLE: - DATE: <br /> �UKAW PLOT PLAN ON REVERSE SIDE <br /> C <br /> FOR DEPA ENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSP CTION <br /> ' INSPECTION BY DATE INSPECTION BY D ��`--'�� ll <br /> Pu .1 A9A Aa,f 19-77 1/7�zM <br />