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------------ <br /> SAN JOAQUIN�LOCALfHEPermit No. <br /> .ALTH DISTRICT i <br /> FFICE USE: 1601 E. Hazel , e., Stockton, CA 95205 <br /> ' <br /> Telephone: . (209) 466-6781 Date Issued L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices ;I Year From Date Issued. <br /> ,Complete Jn Tri p1 i cate <br /> Application is hereby made to the San Joaquin Local, Health Distriacct, forcompliancea permit <br /> to conwith struct <br /> and/or install the work herein described. This application is <br /> �IoaQuin County Ordinance 4,o. 1862 and the Rules and Regulations of the San :Joaquin Local Health - <br /> . - -•; <br /> District. <br /> EXACT STREET ADDRESS 419 IF,iTf4ffiZ CITY/TOWN <br /> Phone `f �����;� — <br /> Owner' s Name . ON ()L� <br /> Address �.. City <br /> EContractor`s Name , G R W L <br /> License# 03 Phone 2 <br /> IS .CERT.I F.ICATE OF W0TZKf1AN_'S.- COIM.PENSAT.I0N._.I.t4SU.RA*,,ICE_0r.1._F.IL£W-I-T�i_SJLND? <br /> I TYPE 76F' WORK-(ChecC) NEW WELL_L __ DEERENIL7-.„ -RECONaITION-[3—.-.DESOTHECTf- N Q� <br /> WELL CHLORINATION WELL ABANDONMENT CI <br /> PUMP. INSTALLATION 0, PUMP REPAIR❑ PUMP REPLACEMENT C] <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 /> e INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� <br /> Industrial - -Cable .Too!, _. D�a. -of Wel l Excavatio <br /> -r <br /> ��Domesti c/pri vats11 ed Dia. ofWel 1 Cas i ng� <br /> Domestic/public prfven - Gauge of Casing <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout CEP7 � <br /> Disposal Other Other Information <br /> f Surface Seal Insta led b <br /> k Geophysical <br /> PUMP IN TALLATION: Contractor. /~I. /lass r" "" " H.P. <br /> Type of Pump -- <br /> 1 PUMP REPLACEMENT: Q State -Work, Done <br /> PUMP REPAIR: OState; W6rk 'Done <br /> ( DESTRUCTION OF 'WELL: Well Diameter <br /> Approximate Depth /.So • <br /> Describe Materia an _-Proce ure <br /> I hereby certify that I have prepared this application and that the work will ,be done in accordan( <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Loc a' <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 Wok-man's Compensation <br /> laws of alifornia." f--�- -- - <br /> , I WILL CAL R GROUT IN CTION PRIOR TO GROUYI-NG--AND- A FINAL INSPECTION. g <br /> SIGNED 6,2 u,' <br /> FOiPi�!/�i <br /> E: <br /> TITLE DAT <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> ' PHASE I .. ,.�.-. DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> -.PHASE--II:-GROUT INSPECTION-- -- =— �-� PHASE-III FINAL INSPECTIQN <br /> ,INSPECTION BY DATE -/3- �. <br /> '/ INSPECTION <br /> Iru 1 AOa . Doti, 19-77 <br />