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•S i1 '-L'��4 <br /> w� SAN' JOAQUIN LOCAL HEALTH DISTRICT ' <br /> E. Hazel ton Ave, , Stockton,:CA 93205 Permit PNo. 79 <br /> _ Telephone: (209) 466-6781 . <br /> -- Date Issued <br /> A?PL"I N FOR WELL CONSTRUCTION OR PUMP PERMIT . . <br /> 2 <br /> JUL <br /> 13 19T9 <br /> Nump I ete In Triplicate) a 4 <br /> A.0i-j1ication lalthe San Joaquin Local Health District for a permit to construct`` . <br /> and/or instal . n described. This application is made in compliande ;with;San <br /> ,'oaquin County Ordinarce No." 1862 and the Rules. and Regulations' of..the San Joaquin Local° Health„.t' <br /> U1sLrlct. <br /> £};ACT STREET ADDRESS O CITY/TOWN; <br /> Oarner's Name <br /> Phone <br /> Address / ` City <br /> Contractor's Name License#,� -7w Phone k <br /> k <br /> IS CERTIFICATL OF '.�f0rK.TAFI'S C77E"1S TION INSURANCE ON FILE WITH SJLHD? YES <br /> s TYPE OF WORk (Check) : NEW WELL 0 DEEPEN[14: RECONDITION Q D?ST RU CTI ONE]. ?; <br /> WELL CHLORINATION L3 WELL ABANDONMENT.-E3 OTHER <br /> PUMP I NS'i ALLAT10N I;R PUMP REPAIR© .. PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER' LINES PIT PRIVYr <br /> _ SEWAGE DISPOSAL -FIELD CBPWL/SEEPAGE ffr— - OTHER .,. <br /> PROPERTY LINE - PRIVATE70 ESTIC WELL PUBLTUDWESTIC Wat- r <br /> !t! INTENDED USE TYPE OF WELL CONSTRUCTION 5PECTfICATTQNS ;V1. <br /> .i Industrial fable To -,{ Dia. of We —Excavation - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack . Depth of Grout teal <br /> Cathodic- Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> x Geophysical r Surface Seal Installed <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: C1 State Work Done � <br /> PUMP RSR-: P5tate Work Done .� 2 <br /> DESTRUC7!0N OF WELL: Well Diameter 5 A roximate_Depth V <br /> Describe Material ana Procedurea= <br /> w <br /> I hereby certify that I have prepared this application and that the work will be done in accoriin <br /> �. with San Joaquin County Ordinances, State Laws, and Rules .and Regulations of the San Joag6in'Local: := <br /> �?ealth District.. Home owner or licensed agent's signature certifies the following: <br /> certify that in the performance of the work for which this :permit is issued, I .`shall <br /> iot employ any person in such manner as to become subject to Workman's. Compensation <br /> laws of Californ0a.” <br />! I WILL CA', L FOR A. GROUT INSPE ON P IOR TQ GROUTING AND A FINAL INSPECTION. <br /> lIW F rl ._ ' ,, -.` ITLE: r DATE <br /> ,a <br /> _ — ADRAW 01 MT PLAN ON REV <br /> ME SIDE) <br /> FOR DEPARTMEN S N Y F <br /> r': 1Sr <br /> 9 <br /> AC%rPTCL i BY DAFTS . <br /> M at j <br /> ! k!n5'_ .f cRo,_'T INSPECTION PHASE III NAL ION <br /> _.__. DATA INSPECTION B 2 <br /> _ js _ 5/19 <br /> - n <br />