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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazeltbh Ave r, Stockton, CA 95205 Permit No.75�.isfss <br /> Telephone: '(209) 4.6.6-6781 <br /> Date Issued i�)s 728' . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP, PERMIT <br /> This 'Permit Ex fres 1 Yeaf From Date Issued <br /> Complete I'n Triplicate { <br /> Applicatiom is hereby made to the San Joaquin Local Health District fora- permit to construct <br /> and/or install the work herein described. This 'application is made. in. compl.iance 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 3 A4,1et 4C7 �' - . CITY/TOWN . <br /> k <br /> ' Phone <br /> Owner's Name ea.n k6 <br /> Address- . 4"Wo—I ; j,,4, C7.ty . ... .. <br /> Contractor' s Name ' Li cense# / , - hone <br /> IS CERTIFICATE OF WORKMANIIS rTAPEP TION INSURANCE ON FILE WITH SJLHD? YES ,30 � <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION DESTRUCTIONCI <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER (: <br /> PUMP INSTALLATION Q PUMP REPAIR Q PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER MI <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 /> -X, - Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel 'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor s4 1 <br /> i I <br /> - Type of Pump H.P. , <br /> PUMP REPLACEMENT: State Work Donei7 ' <br /> PUMP- REPAIR: QState Work Done <br />' DESTRUCTION OF WELL Well Diameter --`��'App-roximate--Depth-------i;— <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 /> lHeal.th 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." ' <br /> I WILL CA L FOR A GROUT ISPC ON PRI R TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E / 4& <br /> ITLE. DATE: 0 <br /> W-W PLOT P NON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .. <br /> DATE <br /> kAPPLICATION ACCEPTED BY / <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE F NAL INSPECTION <br /> f INSPECTION BY DATE INSPECTION BY DATE�� �� <br /> ' riI inn n_._ 7A 77 .. - /78,x, .2M.�, <br />