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SAN JOAQUI,N LOCAL HEALTH DISTRICT FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-7,f-'L.47 61 I Telephone: (209) 466-6781 ' APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued This Permit Ex ires' l Year From Date Issued Complete In Triplicate Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is' made , in compliance with San Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. EXACT STREET AnDRESS—yL If t/y ��_ a ��-,y - - CITY/TOWN �c, ��= -_--__ Owner's Name R Phone j. Address Am L Cfty_,FZ ,,a 404 Contractor's Name License Phone IS CERTIFICATE OF WORKMAN'S COMPENSATIO?1 I1I0.11RAmrr ON FILE WITH SJLHD? YES I40 TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ WELL CHLOINATION 0 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR[1 PUMP REPLACEMENT DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINESSD PIT PRIVY y SEWAGE DISPO 1S L-FIELDS CESSPOOL/SEEPAGE PIT --� OTHER-- �� PROPERTY LIN �,#PRIVATE DOMESTIC WELL-,T6-1--f- PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial Cable Tool Dia. of Well Excavation 1211 Domestic/private Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing 1 Irrigation Gravel Pack Depth of Grout Seal Cathodic Protection _Rotary Type of Grout Disposal Other Other Information Geophysical Surface Seal Installed by: PUMP INSTALLATION: Contractor Type of Pump — H.P. PUMP REPLACEMENT: []State Work Done PUMP "REPAIR: Q State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 3 I hereby certify that I have prepared this application and that the work will be done in accordant with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent' s signature certifies the following: "I' certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman 's Compensation laws of California." I WILL CA FOR A GROUT IN ECT N P I TO GROUTING AND A FINAL INSPECTION. � `'' SIGNED TITLE: DATE: DR PLOT PLVN ON REVERS DE FOR DEPARTMENT U E ONLY PHASE I APPLICATION ACCEPTED BY2"� DATE ADDITIONAL COMMENTS: PHAS GROUT INSPECTION PHA5E I INAL INSPECTION INSPECTION BY ATE__ ,141. 7S INSPECTION DATE 1� r 1AIG ❑— 4e) 'l `iv lAi" I ! 1 1-70 7A}