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SAN JUAQUIN LUCAL HEALTH UISIRICT <br /> FQR FFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. .l`3 <br /> Telephone; (209)' 466-6781 <br /> JV A APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 2Z <br /> This Permit Exp."ires l Year From Date Issued <br /> Complete In Triplicate � to-- / <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 /> k-oaquin• County .Grdi�nance No. 1862. and the Rules and Regulations of the San Joaquin Local Health <br /> E,i s t r;C <br /> s <br /> ��._. j D��Sa'f . tlaE f <br /> s' s rJ.v <br /> EXACT STREET ADDRESS 3dO / W.'of •� a // S rt CITY/TOWN <br /> Owner's Name E✓ �,Ei✓� tella . Phone 77 <br /> Address SZ67 Ci ty:!�L,! <br /> Contractors Name �f Z c �rsT• (:! "O, Li cense#o /Z. Phone C-e _______1 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE.-OF WORK (Check) : - NEW WELL L DEEPEN O -RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION E3 WELL ABANDONMENT [F1' OTHER 0 <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT 0 <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION $P,ECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /Z" <br /> Domestic/private -'Drilled Dia. of Well CasingZ // <br /> Domestic/public Driven - Gauge of Casing 114 <br /> I°rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION:: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Z Approximate Depth �e <br /> Describe Material an Proce ure Yl � ,�„ „00 a ►^o+�+ <br /> s <br /> Ur fec ce• t ,. 3' o.w 41 <br /> I hereby certify that I have prepared this app ha <br /> application and teat the work will be done <br /> in accordancE <br /> with San Joaquin County Ordinancet,' 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 />' 1 WILL ALL FOR A G OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: �.4t - -�7DATE: (� ZAA <br /> DRAW PLOT 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 INSPECTIO <br /> INSPECTION BY '. DATE. �( _ INSPECTION BY DATE2- <br /> 1 <br /> 1 /78 2M <br />