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SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209): 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9`3-7 <br /> This Permit 'Ex ires 1 Year From Date Issued <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 i.n compliance with Sane <br /> Joaquin County Ordinance. No. 1862 and the Rules, and Regulations of- the San Joaquin. Local Health <br /> District. <br /> EXACT STREET ADDRESS '^ CITY/TOWN <br /> Owner's Name j r1JL,af 1 f`;-r�p(��..,. t�,eta�.._ � � Phone lay- <br /> Address- )E—Mg, _ i r . Ci ty <br /> Contractor'.s Name License# S Phone 6 6 e/ <br /> IS CERTIFICATE OF _WORKMAN'S COM ENSATION INSl3RA"CF ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION O <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION J9— PUMP. REPAIR❑ PUMP REPLACEMENT [1 <br /> DISTANCE TO NEAREST: SEPTIC TANKn - SEWER LINES 6'X` - PIT PRIVY <br /> SEWAGE DISPOSALIELD ' -CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINU RIVATTEE DDO ESTJG, WELL PUBLIC DOMESTIC WELL <br /> IN ENDED .f1SE TYPE OF WELL CONSTRUCTION 5P£CIFICATIONS <br /> Indust-ria,l—o-. ., Cable Tool Dia. of Well Excavation <br /> L. omest c/private Drilled Dia. of Well Casing <br /> Domestic/public �\ Driven - Gauge of Casing <br />—Ir m rigation Gravel Pack Depth of Grout Seal- <br /> Cathodic <br /> eam <br /> Cthodic Protection Rotary Type of Grout <br /> D.ispo'sal "" Other Other Information <br /> Geophysical; _ r Surface Seal Instal ed by: <br /> PUMP INSTALLATION: . Contractor <br /> :. _Type of Pump SI:s H.P. <br /> PUMP REPLACEMENT: J1 i Q State Work Done <br /> PUMP REPAIR:. Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �- Describe Material and Procedure ' <br /> � r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , .State Laws, and Rules and Regulations-of the-Saran-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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE- DATE: <br /> DR W "PL T PL N ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,f►�� DATE <br /> ADDITIONAL COMMENTS : )9 <br /> ;PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Cu i A Oc .n_.. 1 n -7� .. .-.., .,�. <br />