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SAN JOAQUIN LOCAL }HEALTH DISTRICT <br /> FORStockton, CA 95205 Permit No. �3� <br /> rFFICE~USE: 1601 E. TelephaneAve(20� ) 466-6781 <br /> Date Issued 3"J6— <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Trip icate <br /> Pict for a permit to construct <br /> Local Health Dist p <br />� Application is hereby made. to the San Joaquin - <br /> and/or .install the work herein described. This application is. made in compliance with San ' <br /> . oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquinoito al Healt}i <br /> E 0?strict.� <br /> tg <br /> E'l(ACT STREET aF�jU,� GG�(b P�1 - CITY/TOWNOwner's Name Phone <br /> City <br /> Address 1.4g A <br />� <br /> Contractor's Name <br /> Li cense# c9 Phoneme-3 <br /> 'S CERTIFICATE OF WORKMAN'S COMPENSATION! INSURAINCE ON FILE WITH SJLHD? YES i aaO <br /> TYPE OF t4ORK (Check) : NEW WELD} DEEPEN ❑ WELL ABANDONMENT <br /> C] DESTRUCTION O <br /> WELL CHLORINATION ❑ PUMP REPAIR❑ NT 0 OTHER MP REPLACEMENT <br /> PUMP INSTALLATION El <br /> DISTANCE- TO NEAREST: SEPTIC TANK SEWER LINES/a PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD _ CESSPOOL/SEEPAGE PIT OTHER r, <br /> E PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Industrial � L „ <br /> _Domestic/private Drilled ! Dia. of Wel 1 Casing 0 <br /> Domestic/public Driven Gauge of Casing /a <br /> Irrigation Gravel Pack Depth of Grout Seal C <br /> Cathodic Protection Rotary . Type of Grout <br /> '—Disposal Other Other Information r �� <br /> Geophysical Surface Seal Instal ed by:-. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump F� --.:...�-� H.P. <br /> PUMP REPLACEMENT: ,[Rj State-_Work' one � <br /> PUMP REPA.IR.:- QState Work Done y Y <br /> DESTRUCTION. OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I herebykcertify that I have prepared this applica-t-i-on....and .7that- the-work will- be done in accordan <br /> fwith San'�Joaquin County Ordinances , State Laws, and Rules and -Regulations_of% the- San Joaquin Loca <br /> Health District. Home owner or licensed agent' s signature certifies the foll-owing,: <br /> "I certify that-�i.n_ the performance of the work`"for w.hich_th'i.s_permit is i-slued, -I. shall <br /> `not employ any person—i.n- 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 /> k SIGNED <br /> ITLE_;� DATE:3 fa,21 ? <br /> DR W PLOT PLAN ON REVEQ S-I-DE- _ <br /> FOR DEP-115.1Z,11MENT USE ONLY , ,f <br /> ' PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II °GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,��i_ DATE � — INSPECTION BY =E DATE i <br /> 1 2N <br /> � ru 1 ear 0_77 - <br />