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SAN JUAQUiN LULAL HtA��1H UIS1KiLi - ---- <br /> 010E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 3 <br /> Telephone: (209)' 466-6781 } <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fires 1 Year From Date Issued ' <br /> —A).. ` Complete In r:ip icate ► <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 in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. oma 22*vi5 P-D <br /> EXACT STREET ADDRESS 0, Ml' & OF CITY/TOWN LDO/' <br /> Owner's Name WAW 0& '$6 • 7- L Phone 4_4�(v s <br /> Address <br /> -3-7 � V� City_ 17�.f/ <br /> Contractor's Name /$ i� IKEc� `U,Pa�[1rV_ CT_ __ License# O 'phone 3 37'7 ; <br /> IS CER IFIC E 4F 14Or,KMAtI_S_ CO`1pEtaSAT_IO'l_IraSURA"lC.E 0d_FI.LE 41ITH__S.JLHD? YES.__ _ <br /> TYPE OF`WORK�Check N W WELL DEEPEN � _I_0N-❑" DE�RUM:dkT_]w <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ � <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT �. <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK 3�SEWER LINES 3®LD PIT PRIVY -----��SEWAGE DISPU9[7IELD ----��SP OL/SEEPAGE PIS �THER j <br /> PROPERTY LINE PRIVAT-E—D-ORESTIC WELL-­N0P_ PUBL C DOMESTIC WELL <br /> INTENQEQ USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ <br /> Industrial a Cable Tool Dia. of We Excavation '`� <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Depth of Grout Sea <br /> rrigation Gravel Pack D ! <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information t <br /> Geophysical Surface Seal Insta ed_b <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ` <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCION-OF-IJELL: "'We11�`Diameter `' P� `° trs�Dpth`� <br /> Describe Material and, Procedure <br /> ` I hereby certify that I have prepared this a�a�,plication and that the work will be done in accordancE <br /> � with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the. San 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 /> vA <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. DATE. <br /> SIGNED TITLE. <br /> L N ON REVERSE IDE <br /> j. F R DEP MEN USE NLY <br /> SE I DATE 'L, <br /> mr,'LICATION ACCEPTED BY <br /> ADD ITIONAL=:'COMMENTS: 3 PHASE III FINAL INSPECTION <br /> :, ` ' PHASE II GROUT INSPECTION- " <br /> t :.O DATE % l0'"7 INSPECTION BY, Cyd DATE z,7 �� <br /> INPTI01r8Y <br /> = 1 78• 2M <br />