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{{ � t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF : USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. .2 <br /> Telephone: (209) 466-6781 <br /> APPLI'ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3-IS-7`t <br /> (Complete In Triplicate) <br /> Application is herehy made to the S.,n Joaquin Local Health District for a permit to construct <br /> and/or install th^ 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 a.LGa a5oort ,r CITY/TONIN <br /> Owner's Name-�� �_'. � .,�� L.,. , r c. 1, Rhone <br /> Address -, y <br /> sCi tJ' <br /> Contractor's Name License#/ 3-?xI'�Phone_ <br /> I5 CE____RTIFICATE OF' w0'tilAN'S CO"'f'rNSATI t! INSURA"10E ON FILE WrTll SJLHD? YES X <br /> No <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER❑ G� <br /> PUMP INSTALLATION Da PUMP REPAIR 0 PUMP REPLACEMENT C3 � <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPI SATTIELD C ML/SEEPAGE PIT OTHER <br /> PROPERTY LIME - PRIVATr-WESTIC WELL PUBMWESTIC AEL'C+ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> TnTu-s—trl a Cab a oo Dia. of Well Excava-tTon <br /> :'Zomestic/private Drilled Dia. of Well Casing <br /> — Omestic/public <br /> _ <br /> _Irrigation Driven Gauge of Casing <br /> g Gravel Pack Depth of Grout seal <br /> Cathodic Protection Rotary Type of Grout <br /> Dfispi <br /> .—Geophysical Other Other Information <br /> Surface Seal Insta e <br /> PUMP INSTALLATION: Contractor t <br /> Type o r Pump���3�L��c y 1+ H.P. <br /> PUMP REPLACEMENT: . <br /> -- p State Work Done <br /> PUMP : QState Work Dore <br /> (JE�''RUCTION 0__—i"El.L: Well - <br /> ?ia+nMate Approximate Depth <br /> Describe �ta�er�-�n roce ure <br /> I hereby certify that I have Prepared this application and that the work will be done in accordance <br /> with San Joaquir County Jrdin,iice, , State, Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District, Hare Owner or licensed agent-1s, signature certifies the following. <br /> "1 certify that in the veto rr+tlr,ce of the work for which this permit is issued, I shall <br /> not employ any person ill ;,;c" -ianner as to become subject to Workman's Compensation <br /> laws of California. " <br /> ' WILL CALL FOP A GROUT . IS 171; PRIOR. TO GROUi'ING AND A FINAL INSPECTION. <br /> TITLE: "i--' DATE; � <br /> JN �EV <br /> f'�+.SE '.._,-. _...,_---F =,E A?I TTgrti SSE <br /> IUV— <br /> YI 'N ACCEPTED R <br /> P" <br /> �rTIq`AL Cti^''�'E."�T5 - -- _._ ,� __t,. - 'l cr• __ DATE =/ !/ 79 <br /> I"{A5_�_ __I <br /> '"SPE'CT?0y RY -- PHASE III FINJL INSPECTION <br /> 11 0/71 _._._. ._._ INSPECTION P.Y� DATE SIl 7 <br /> 2 Rr•., <br /> �.*� Q17n <br />