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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - 6 <br /> Telephone` '(209) 466-6?81 Date Issued ��dl <br /> 79 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires l 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 f <br /> and/or install the work herein described. This, appli.cation is made in compliance with San <br />,oaoui.n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local .Health <br /> District. <br /> EXACT STREET ADDRESS .2 d l JP 7 G, v , C TY/TOWN , 'Sc-o aAJ <br /> Owner's Nave AELAAEPLi z,q- Sv <br /> Address r <br /> Contractor' s Name L L 09JLL_)/VgLicense#.yfZg/z3 PhonelQof 2 3,6 _ 6 <br /> I5 CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES N0 ✓ <br /> TYPE OF WORK (Check) : NEW WELL Ij?. DEEPEN Q RECONDITION [] DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL 'ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Jjj� PUMP REPAIR❑ PUMP REPLACEMENT [J oa <br /> DISTANCE TO NEAREST: SEPTIC TANK `7SI SEWER LINES/6v ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC TELL 4`0' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ��Cable Too! Dia. of Well Excavation ,2 " <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary ¢ Type of Grout CQ � <br /> Disposal - Other Other Information <br /> Geophysical --7 _ Surface Seal Installed b r,/ er <br />'UMP INSTALLATI-ON-:-, C-0 n t r a c t 6 F. 14.,fin• rx <br /> Type of Pump i 4 Me 4.7 Je _ _ H.P. <br />'UMP REPLACEMENT: []State Work Done <br />'UMP REPAIR: - OState Work Done <br />)ESTRUCTION'OF. WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> Lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ` <br /> leal�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. " I " <br /> WILL CALL FOR A G T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> D_Z&� TI`TLE.: C�}- c am ., DATE: -?— 1S1-7;5r'r <br /> (DRAW PLOT PL N ON REVERS IDE <br /> FOR DEPARTMENT- USE ONLY k <br />'HASE I <br />,PPLICATION ACCEPTED BYDATE 7 / <br /> iDDITIONAL -COMMENTS <br /> PHA I GROU INSPECTION " <br /> PHASE III INAL INSPECTION <br /> NSPECTION BY VuLkvp4i ATE INSPECTION BY DATE �-- <br />