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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave-, Stockton, CA 95205 Permit No. . .�. <br /> Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires L Year. From Date Issued <br /> 22e �.Z„q',� �p .. '! ' 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 descriijed:` This application is made i!n compliance with San <br /> I �'oaauin County Ordinance No. k862 and the Rules and Regulations of. the San Joaquin Local Health <br /> E J 1 S t!'i C t. 4IZ rr+• w eiCj�ts AFF J .ri�d4. °'k SISI , <br /> i EXACT STREET—ADDRESS T Ivy f nL- . S 0 CITY/TOWN <br /> F Owner' s Name G�'1�v�Jr (�k 1 PhoneAddressWIR <br /> Ci ty S'lbutl d",_ <br /> Contractor' s NameCl- ' ,1z <br /> AM- <br /> Id Phone2_ <br /> IS CERTIFIGATE':.1Oi' WORKMAN'S cQMPENSATIO"I I11SURANCE ON FILE WITH= ,JLHD? YES���`NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION* ] DESTRU,C ION[� <br /> t WELL CHLORINATION Q WELL ABANDONMENT 0 0T'1iER ❑(PUMP INSTALLATION ❑ PUMP EPAIR.n PUMP/REP,LAGEMT_ l s <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PR•IVY -7 <br /> t <br /> SEWAGE iDISPOSAL FIELD -`-- CESSPOOL/SEE=PAGE%TIT OTHER <br /> PROPERTY LIN£ VJPRIVATE DOMESTIC WELL '��_' ROk IC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL. ' <br /> /. - : <br /> COi�S�TRUCTION SPECIFICATIONSIndustrial _Cable fool DianFW'eTFI Excavation <br /> Domestic/private Dr� l'led' Dira°.. of Well Casing <br /> Domestic/public, Driven, , Gduge o�f``Casing �— <br /> Irrigatian . : n GravelPack /Depth ,of Grout Seal <br /> Cathodic Protection -y_ .1_ � , Rotarl Type of Grout <br /> Disposal . , ,zOthe'r' Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor' <br /> Type ofPUMP ,� / H.P. <br /> PUMP REPLACEMENT: <br /> ❑Stage Work Done <br /> PUMP REPAIR: ❑fit to Work Done" , <br /> DESTRUCTION OF WELL: Well Diameter ''` Approximate Depth <br /> D`escri be Material an Proce u' e ! <br /> I- her.eby-„certi fy -that-I-have -prepared this appl i cation_and that the work wi 1..7. be done i n accordance <br /> with San Joaquin County.-Or-dinances�; State`Laws-, and Rules and Regulations of the San Joaquin Local ! <br /> Heal=th'-District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify/' hat 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 o.i Cali for 1! < < <br /> I WILL CALL 0 OU �P.ECON,PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 5 GNED� TITLE: V C 4A DATE: 0 � ,I <br /> 4. • i, DR W PLOT PLN ON REVERSE S1DE,`,"4 , ti, A -1 A. <br /> 7 eF R DEP RTME T USE ONLY <br />'HASE I _ . <br /> APPLICATION ACCEPTED BY k y DATE lel7F <br /> ADDITIONAL COMMENTS: <br /> PHASE II//ROUT INSPECTION PHAS II INAL INSPECTION <br />;NSPECTION�'BY / DATE tiNSPECTION BY DATE G z Via- r <br /> .� <br /> H 7422 Pail -1'7_77 � � .. � _ _ F <br />