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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br />.'OR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. IF-616/Z_ <br /> Telephone: (209) 466-6781 Date Issued .. <br /> -�r--4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This _Permit Ex ices 1 Year From bate Issued <br /> Complete In Triplicate) <br />?plication is hereby made to the San Joaquin Local Health District for-a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San <br /> oanuin County Ordinance No. 1862-and the Rules and Regulations of the San Joaquin Local Health <br /> istr�ct. <br /> XACT STREET ADDRESS CITY/TOWN, <br /> wner's NamePhone ��a a e <br /> n <br /> ddress n City- <br /> 410 <br /> ity <br /> ontractor's NameN/ ply' � - <br /> License# '/U Phone -9 5'703 <br /> �'S rrRTrcTrdTG OF WORKMAN'S rnMQENSATIO" INSURANCE ON FILE GITH SJLHD? YES NO <br /> - <br />'YPE OF WORK {Check) : NEW WELLt. DEEPEN ❑ RECONDITION C3DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERt MENT W <br /> PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACE [ I <br />)ISTANCE TO NEAREST: SEPTIC TANK SO 4- SEWER LINES =—PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD 5-0+ CESSPGOL/SEEPAGE PIT10a� OTHER <br /> PROPERTY LINE/d.'tPRIVATE DOMESTIC WELL �PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 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 /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Mary Type of Grout hp�.�y:—� gf— <br /> Disposal - Other Other Information <br /> Geophysical Surface Se Installed by: <br /> PUMP INSTALLATION Contractor r%-Isl PC, P� <br /> Type of Pump H• <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />.I hereby certify that I have prepared this application and that the work will be done in accordanc <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 WI LL FOR A GROUT N IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE - DATE: 7 <br /> PLOT PL N ON RE S SID <br /> FOR DEPAR USE ONLY <br /> PHAS DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> FLASk JI GROUT INSPECTION PHASE IIKEINAL INSPECTION <br />'INSPECTION BY DATE - �� INSPECTION BY DAT 'b"fig <br /> -----r 7.8 2M <br /> IEH 1426 Rev. 12-7 <br />