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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE�USE:­ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9 - 7 3� <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (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 described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San J aqui�n Local Health <br /> District. <br /> EXACT STREET ADDRESS o 6 i &� CITY/TOWN <br /> /© j <br /> Owner's Name F.6i 1° r- O . S. <br /> Phone ftp- �Z�l <br /> Address Ci ty S oc , <br /> Contractor' s Name %YIO C C lOC Li cense#P�' SPhone 5�l6 �7/-�32 � <br /> s <br /> TS CERTIFICATE OF WORK?IAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO � <br /> o <br /> TYPE OF WORK (Check) : ffE WETOL,'O DEEPEN 0 RECONDITLO..,0 DESTRUCTION[] �1I <br /> 0A1ENTWOTHER Q WAE <br /> PUMP INSTALLATION Q PUMP`REPAIR Q PUMP REPLACEMENT CO <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> s Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seams <br /> Cathodic Protection _Rotary Type of Grout oe��r <br /> Disposal Other Other Infarmation <br /> g eopliy_s-c Surface Seal Installed b : <br />, kMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I' PUMP REPLACEMENT: Q State Work Done <br />'j PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure ;(/ r Gro <br /> j I hereby certify that I have prepared this application and that the work will be done in accordant( <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 . " <br /> I WILL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: ssf dp , DATE: -.2�7� <br /> DR W PL T PL N ON REVERSE SIDE c/'h` P <br />' F DEPARTMENT USE ONLY -� <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE 11 GROUT INSPECTION PNASL,_.1-NSPE-CT1P <br /> INSPECTION BYDATE INSPECTYONJBY ATE S` <br /> f �_ <br />