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OkiSANJOAQUIN LOCAL,HFALTH DISTRICT <br /> ,Gd-f � 4q'" I <br /> FOR OFFICE Ub< u 1601 E. Hazel�tori Ave. , Stockton;; CA `,95205.: Permit No.. <br /> Telephone: (209) .466 6781 , <br /> ar ADate <br /> Issued. <br /> APPLICATION.-FOR WELL CONSTRUCTION 'OR -PUMP PERMIT <br /> tip? <br /> This Permit Ex fires l Year From: tiate .I,ssued <br /> Complete In ..Triplicate . <br /> Application is hereby'made to the San Joaquin Local Healthy District for a permit .-to construct <br /> and/or install the work herein described: This application is made in compliance withSayf� <br />,Ioan�jin County Ordinance No. 1862 and, th Rules and .Regulations of the. San Joaquin Local Health <br /> EXACT STREET ADDRESSCITY/TOWN <br /> -� <br /> Owner' s Name a Phone <br /> Address CityV�_� <br /> Contractor's Name V, � ,JLi.cense • d Ahorie <br /> J �> � <br /> I$ CERTIFICATE OF WORK�IAN'S C IPENSATIO"l I1ISURA^!CE ON FILE WITH SJLHD? YES u`nN0 , <br /> TYPE OF WORK (Check) : NEW WELL��DE£PEN G RECONDITION [ DESTRUCTION'] <br /> WELL CHLORINATION Q WELLABANO.ONMENT CI OTHE,R;F-3 <br /> PUMP INSTALLATION .0 PUMR•--REEPAI-R-Q_---PUM^P R L=A0E�+1E-N Q—� <br /> DISTANCEtTO 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. SPECIFIC TIONS <br /> Industrial Cable Tool Dia. of Well Excavation' <br /> �mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Mary Type of Grout <br /> ,Disposal Other Other Information . <br /> Geophysical Surface Seal Installed <br />� PUMP "INSTALLATION: ,Contractor <br /> Type of Pump H.P. f <br />' PUMP -REPLACEMENT: []State Work Done <br /> PUMP.REPAIR: p State Work Doney a <br /> DESTRUCTION OF WELL: Well Diameter - ��• Approximate-Depth <br /> Describe Malterial and Procedure 24. <br /> II hereby 'certify that—I, have prepared the s applicationand that the work. wi 11 be done in accordance <br /> with San Joaquin CountyOrd,ananc.es , State -Laws , and 'Rules. and Regulations of the San Joaquin Local <br /> Health District. °-.Hbmerowner or licensed agent' s signature certifies the following: <br /> "I cer' t in the performance of the work for which this permit is . issued, I shall <br /> n employ an per n such manner to become subject to Workman' s Compensation <br /> laws of Cali ornia. <br /> I WIL ALL FO A -GROU .I T IOR TO .GROUTING AND A FINk INSPECTION. <br /> SIGNED <br /> -�-r.-_ TITLE a DATE: <br /> x _ _-..DR W PLOT a.PL N ON REVERSE SIDE) <br /> FOR DEPARTMENT FUSE ONLY p_ . <br /> IPHAS£ 'I DAAPPLICATION ACCEPTED 6Y <br /> ADDITIONAL COMMENTS: ~ <br /> PHASE II GROUTL: INSPECTION ' -PHASE III i NAL INSPECTION__' <br /> !INSPECTION BY DATE INSPECTION ''QY DATE it <br /> �. _. <br /> CU 1 Ar1C D.... 1077 -- <br />