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SAN JOAQUIN LOCAL..HEALTH DISTRICT <br /> PT'CE"iISE: 2601 E. Hazelton Ave. ,- Stockton, CA 95205 Permit No. <br /> Telephone:: (209) 466-6781 2 419 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5--� <br /> This Permit. Expares 1 Year From Date Issued <br /> Complete. In Triplicate) Iq ;,-) : 6,S <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 /> Di s -n7c . - k <br /> � .l9 ...Sc►ilt .i..o�4fJD �/i/ G�� C ��EDTD <br /> EXACT STREET `ADDRESS D E �� CITY/TOWN ,Lea.91 <br /> Owner's Name ec-` E'pp .,. <br /> Phone <br /> Address 7A23 /Gi/�4 „2- J/ Cit'.. e:?�5�. p. Ci t- <br /> Y L o /.. <br /> Contractor' s Name<jJ SOAJ - �� <br /> +;Li cense#3370e?�Phone - _33_7`7 <br />' TS CERTIFICATEOF WOP,K11A'd1Sr CO'iPENSATIO'!-I'ISURA'."lCE,?Of,d FILE WITH SJLHD? ' YES- <br />, TYPE <br /> ES `' TYPE OF WORK (Check) : NEW WELLS DEEPEN 0 R£0 DITION CJ DESTRUCTION C2 <br /> WELL CHrORINATION Q WELL ;ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION M PUMP ;REPAIR Q PUMP REPLACEMENT 0 I�I <br /> • 4> P <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE IT --ETHER <br /> PROPERTY LINEAOPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled :Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing i p <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection Rotary <br /> Type of Grout <br /> Other Information <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State .work Done {' <br /> PUMP—REP-AIR.: .��.,r;�(]State_WWor <br /> k--Dane <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Mate ria and Proce ur:ef., <br /> Approxima-te Depth <br /> I hereby certify that I have prepared this application and that the work will :be done in accordancek <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 ffbr which this permit is issued, I shall <br /> not employ any person in such manner als to become subject to Workman 's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR T0'- ROUTI:NG AND A FINAL INSPECTION. <br /> SIGNED TIiLLDATE: <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> PHASE I f FOR DEPARTMENT. USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE_ <br /> k - <br /> PHASE I.I _GRO,UT I1VS.P_E.C_T_I.O.hl _PHASE -I I-I FINAL—INSPECTION <br /> INSPECTION BY DATE IWS-P-ETE <br /> CT!ON; B:YY _ _. - ��•,7�/ <br /> r k <br />:H 1426- Rev. 12-77 y <br />