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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazel;ton. Ave(20. , Stockton, CA 95205 Permit No <br /> Telephone: 9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date issued _ 7 6 <br /> This Permi't Ex i.res 1`Ydar From Date Issued <br /> Complete In. Tri pl.i tate ' <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 Joaquin Local Health <br /> District. !! rr p r <br /> EXACT STREET ADDR S '��Z f� 0 Af F C CITY/TOWN.M.41Yrt eA--• <br /> Owner' s Name Phoned <br />' Address - 'l 0- Q Ci.ty C <br /> Contractor's Name AJAL?TIN 0 in fUO ,21.,X Licenseh2 6 6 /6,3 Phone 03 <br /> 174 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM INSURANCE ON FILE WITH SJLHD? YES ?SO <br /> TYPE OF WORK (Check) : NEW WELL K DEEPEN 0 RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 (� <br /> PUMP INSTALLATION J' PUMP REPAIR❑ PUMP REPLACEMENT [I <br />' DISTANCE TO NEAREST: SEPTIC TANK S�0 SEWER LINES PIT PRIVY b <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL' Y � CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br />' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> TXIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _X_Rotary Type of Grou <br /> Disposal Other Other Informa ion <br /> Geophysical Surface Seal Installed by: <br /> ' PUMP INSTALLATION: Contractor '�� ° <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an2 Procedure <br /> 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .A FINAL INSPECTION. <br /> SIGNED 0 TITLE: btVAR—"t ' DATE:_ 3--3-7 ff — <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED B (/�' tG�s" <br /> ADDITIONAL COMMENTS : °"` ""'�` <br /> PHAS II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> 'I INSPECTION BY DATE INSPECTION BY C111 — DATE <br /> a %c� ' '`_ 1 qZ7G�et �. _ l 7$ 211 <br /> FW 7 a9F Rau 19-77.x_ <br />