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o <br /> SAN JUAQUIN LUGAL NLALIM Ui5IHIUI <br /> _FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7F_i3.3,5- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedf_;:,-;�8' i <br /> This Permit Expires 1 Year From Date Issued <br /> m 1 ete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <br /> and/ar 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 /> S t i t 1»•,` Al' Of 1!A ^ 91-L AI '5��Q L a <br /> ExA DDRES �e, 5, � [ I` ��izA, �t Z - CITYJTOWN. '/��G- :,� <br /> -- - a <br /> Owner' s Name FR iq"t 4c Ste, Phone � - _211 -_ -- <br /> Address - - . 2,... n A J • - — Ci ty J,�LC,134.00 <br /> Contractor' s Name_', �,�t, ,. �,1 License#,,2??bi4 Phone 83,?-2-2o-7 <br /> '. S CERTIFICATE OF WORKMN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? _ YES All' I40 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [J —-DESTl IUCTiONo—'' <br /> - <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION [a. PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: ,, SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE .PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 61 <br /> Industrial Cable Tool : Dia. of Well Excavation 5 ° <br /> Domestic/private Drilled Dia. of Well Casing - -_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ._ _.. Depth of Grout Seal <br /> Cathodic Protection Rotary Typd'of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor TD. SUTn1;U <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> e <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> 'Describe'Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant( <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 I PECTI-ON -PR.IOR.,TO GROUTING AND A FINAW INSPECTION. <br /> SIGNED <br /> -TITLE: DATE:Iq -7e9 <br /> DR W PLOT PLAN--,ON-REVERSE SIDE <br /> rROR .DEPART MENT..USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED B.Y. znd DATE <br /> ADDITIONAL COMMENTS: ., <br /> "r :PHASE .II GROUT INSPECTIO PHASE INaFINAL INSPECTION z <br /> INSPECTION SY DATE INSPECTION SY DATE,5P_J Z 74 <br /> CEJ 1 Ane •n_.. n "7' Z /74 7Tuf <br />