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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Zg._�� <br /> FM'J-� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ g' <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> FOlication 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 ulatioris of the San Joaquin Local Health <br /> istri ct. Egli SZ. Ad4ees- 1. Z <br /> EXACT :S,TRE£T ADDRESS FnrI orr"�A#ifA CITY/TOWN ,5-s <br /> �wner' s Name A/ 4 r o f - Phone _S"��- 2- <br /> -Add <br /> — - - <br /> -r+ddressQ��' �t /Qr.� City . ° � <br /> contractor's Name License# Phone_� '�„ �3sc <br /> �S CERTIFICATEF R <br /> O WORKMAN'S' <br /> S COMPENSATION 111SURANCE ON FILE WITH SJLHD. YES X 1140 <br /> YPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ <br /> t WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION.” PUMP REPAIR❑ PUMP REPLACEMENT <br /> 3 <br /> 1ISTANCE TO 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 /> l INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> FU Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> rRUMP INSTALLATION: Contractor _/11--s - <br /> t Type of Pump .. =S'e.,, _')••t eZs I H.P. <br /> � <br /> PUMP REPLACEMENT: 0 State Work Done 1(?ep!,Lee rl�,4 ---- <br /> JMP REPAIR: ❑State Work Done <br /> )tSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> [ hereby certify that I have prepared this application and that the work will be done in accordant <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> �alth 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 /> Elaws of California. " <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> '.iGN£D TITLE: �a�l DATE: <br /> DRAW PLOT PL N ON REVERSE IDE <br /> FOR DEP TMENT USE/ONLY <br /> '.ASE I <br /> PLICATION ACCEPTED BY DATE <br /> ,JDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION RASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BYE Wit' DATE a <br /> s <br /> H 1426 RPv. 12.-77 5-0� � - IV,'O --`MS <br />