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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f7F:FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 5r <br /> Telephone: =- (209) 466-6781 <br /> ' Date Issued ! .. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 1 AJA _f CITY/TOWN ; 7V!3,,� :. <br /> Owner's Name a,4 <br /> Address 4 a,,A �cCi ty <br /> Contractor's Name 0Ad i t/edLicense ?e" Phone Vr,, - 3 ' <br /> t <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0. <br /> TYPE OF, WORK (Check): `;NEW WELL 0 DEEPEN 0 RECONDITION C3 DESTRUCTION[] � <br /> :r [WELL CHLORINATION 0 WELL RANDONMENT 0 OTHER 0 w <br /> n PUMP INSTALLATION ga� PU PAIR O PUMP REPLACEMENT C1 v <br /> k DISTANCE TO NEAREST: SEPTIC TANK D t. f LINES�4 ' PIT PRIVY <br /> ! SWAGE DISPOSAL , . j �' CES�L/=SEEPAGE PIT OTHER <br /> .PROPERTY LA. RITE DOMESTIC��IEl�L`/ PUBLIC D MESTIC WILL - <br /> INTENDED CISE' T�,PE;OF_,WELL., C NSTRUCTION SPECIFICATIONS <br /> Industrial <br /> _ - Cabl a-•Tool4 * <br /> a:ofl� �=E�xcav-a-t-ibn- <br /> omestic/private Drilled Dia'-j f 96),1 .Cas:i Kg <br /> Domestic/pubIic ' Driven �` Gauge of as <br /> _ _ ' rri ation :k - <br /> I 9 Gravel ;Pack Depth,,.yo Grout Sm <br /> Cathodic Protection <br /> ,, RotarY rt" �of. ro "` <br /> —__ Disposal Tye --- <br /> 0ttie^ Otlier'"Information <br /> eophysical . I I.. /_ _ _ _ ,--Surface--Seal>1-hsta e <br /> PUMP INSTALLATION: ' Contractor S <br /> ITyPe of Puinp`t- ,� S p H, <br /> PUMP REPLACEMENT: s py p State' Work Done �w <br /> „ PUMP REPAIR: ' �i ` <br /> ❑State Work� Dane <br /> irREST RUCTiION, OF WELL: We11'°Diameter Approximate Depth <br /> Describe Material and rocs ure, <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-own-e-r-=--e-r 14 censed'agent's s i gnature_certi f i es the following: <br /> I certify-that in the performance of the work for which this permit is issued, I ',shall <br /> i <br /> not em to fan � •�: <br /> p .Y y person in such manner as to become subject to Workman's Compensation_ <br /> laws of California.',' _ <br /> I WILLCRLL FOR ;A_ GROUT:. ,S ECTION PRIOR--TO-..GR{3t1TING=AND' FINAL INSPECTION, <br /> - - <br /> ;SIGNED { <br /> '� TITLE:. DATE: �.. <br /> D W ,PL T L NON REVERSE SIDE <br /> OR DEPA <br /> RTMENT <br /> - USE ONLY <br /> ' <br /> PHASE I ', �'? , � , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III 'FINAL ' INSPECTION <br /> INSPECTION BY o DATE 78 INSPECTION BY DATE <br /> SEH--14 26 fReV. / (a 9 �. 9/7 <br />