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SAN JOAQUI.N. LOCAL' HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued. 7ly' <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) , <br /> Application is hereby made -to the San ;Joaquin Local HeO th' District for a permit to -construct <br /> and/or install the work herein described— This application is made in compliance, with Sman <br /> doaQuin County Ordinance No. 1862 and the Rules and ;Reg-ulationsm-of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS /" ] CITY/TOWN <br /> Owner' s..Name �, Phor �$�-�? <br /> Address— <br /> Ci t <br /> Contractor' s Name .. / License#-4%-0/e,>S3—r Phone <br /> IS CERTIFICATE OF WORKMAN`S .COMPENSATIO"1 INSURA1110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION-.Q DESTRUCTION <br /> -- - - -WELL CHLOR-INATI-ON-Q--- E-L-L ABANDONMENT-0 OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE ,TO NEAREST: SEPTIC„TANK 755 SEWER LINES PIT PRIVY <br /> a SEWAGE DISPOSAL FIELD CESSPOQL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OFWELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '__,,,,Sable able Tool Dia. mof Well Excavation S <br /> �Domestic/private Drilled°- �_� v Dia, of Well Casing d s- <br /> Domestic/public Driven • ����~ Gauge of Casingm <br /> Irrigation Grayej , Pack -Z Depth of Groaneal '� �- r <br /> Cathodic Protection Rotary Type of Grourt m <br /> Disposal Other Other Information <br /> Geophysical Surface Seal instal Ted by: I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �Tc� H.P. • <br /> PUMP REPLACEMENT: En <br /> tate Work Done w' <br /> PUMP REPAIR: ❑State Work Done B '° <br /> DESTRUCTION OF WELL: Well Diameter _ <br /> .1A�roximate. Depth <br /> Describe Material and Procedure �,,..•7 m ` r <br /> I hereby certify that I have prepared this application and:'that'..t.he' work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws, and Rulesmand-Regulations, of the San Joaquin Local <br /> Health District. Home owner or licensed agent's si natur°':ceifes the 'follaS�fin g <br /> "I certify that in the performance of the work f...o-r:whi. Ncan <br /> ch this 'Permit-,;s 1sS,5: ,uE.d, I shall <br /> ' <br /> not employ any person in such manner as to become' subject to rkm 's Com��4sation <br /> laws of California. ” <br /> I WILL CA FOR A GROUT I SPECTION PRIOR TO } 'RO.UTINOm'AND A FINAL NSP;EClIONm: <br />:S:lGNED ..,.- �s. a;� <br /> TITLE: �r a :,rg DATE: o <br /> DRAW PLOT P1t . ON REVERSE SIDE <br /> FOR DEPARTMENT [1�E ,ONLYF „ <br /> PHASE I - s,. h:. <br /> APPLICATION ACCEPTED BY DATE 3 - ? -2 9' <br /> ADDITIONAL COMMENTS: ; Hr <br /> PHASE bI GROUTSPECTI N PH SE I FINAL INSPECTION <br /> INSPECTION BY DATE 'fib � � <br /> r _ IIVSPCTDN B DATES <br />:H-1426 Rev_ 19-77p <br />