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SAN JOAQUIN -LOCAL .HEALTH DISTRICT <br /> OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -7.k 3l 2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year`From..Date Issued <br /> Complete In Triplicate <br /> -s <br /> Application is hereby made to permit San Joaquin LocalHealth District for a to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. ,1 62- and the Rules and Regulations of the an Joaquin Local Health <br /> District. iLs -_ duress tet► - Y l��a.�c�r��.. <br /> EXACT STREET�D�RESS Id 40,olrok &�4eAb CITY/TOWN od <br /> Owner's Name a44, s - K.i.1t P e ' Phone &�� qQ <br /> Address City ' <br /> Contractor' s Name Li c e n,s e#A&E= Phoned <br />_Tf_CRTIFI A_TE FF-kJOT1Z 1'A1�' `CC �4PCJS;tiTI T�I1dSURA*1C 'II I�FTtE'1r1i'TFI SDL"HD? YES 1� O- _ <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION CQ DESTRUCTIONf� �p <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> 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 PUBL.I.0 DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We31 Excavation, <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven - Gauge of Casing . . ..' . ,� <br /> Irrigat ion,.# . F. Gravel Patin/ Depth of Grout Sea _ <br /> 'Cathodic 'Protecti ori k,,_r Rotary pe ofGrau't'� � r <br /> Disposal" , ' � �_.Otrier Other Information <br /> Geophysji cal, ,� "'"' Surface Seal Instal'led,.b ':. k sJ <br /> PUMP INSTALLATION: s-Contractor - -s 4 <br /> Type of Pump " i H.P. <br /> PUMP REPLACEMENT: [I Sta Ie Work Done_: <br /> PUMP.._REP_AI•R' ❑State-Wo rk-Done - <br /> DESTRUCTION OF WELL: Well Diameter x Approximate- Depth <br /> Describe Materia 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 /> 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 /> not employ any person in such manner-as to become subject to Workman's Compensation <br /> laws of California. " w <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: --,�,�=1 <br /> (DRAW PLOT PL N ON REVERSE SI <br /> PHASE I <br /> FORDEPARTM NT USE ONLY <br /> . ,�. - � <br /> APPLIC�ITiON: ACCEPTED BY DATE d 9- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IL.1 71NAL I PECTION- <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> EH 1426 Rpv_ 12_77 osem' - -_ _ .:... __,_',7Q Oma_ <br />