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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR FFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No. 17P-Sp <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-//-Y--7y <br /> This Permit Expires 1 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 <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. <br /> EXACT STREET ADDRESS Q {z I Y/TOWN 7 <br /> Owner's Name 4 A p 04F V 454c Phone a3?-.34-90 <br /> Address i 6AIE City Allef FCC <br /> Contractor's Name Al i---5 License#.3*5'7s": "_ Phone .S'f F-3 jgS <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION I'NSURAINCE ON FILE WITH SJLHD? YES 1C NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION 1Z PUMP REPAIR D PUMP REPLACEMENT J� � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY JY4- `"°r <br /> � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4-1 <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 Seal 41 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Al -i--s <br /> Type of Pump Su m e-r..,-1 H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q 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 accordance <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 i6?14 TITLE: h DATE: 'f hid 79 <br /> DR W PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 41Z& DATE INSPECTION 4kDATEr�-7r <br /> EH 1426 Re 2-7 c' 4- 1 7 <br />