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SAN JOAQUIN,;LOCAL .HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave .,,, Stockton, CA 95205 Permit No. <br /> I Telephone: (209) 466-6781 <br /> Date i Issued `°APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - <br />' Ths' Permit Ex ires. 1 Year From Date Issued <br /> t (Complete In TriplicateY 7 - ��� <br /> Application is hereby made tof the San J�aqu.i n� L�ca1� :Hea1 th District ct for .a r ` <br /> perms t. to ?onstruct <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. <br /> EXACT 'STREET ADDRESS Z/Qoo. 1 �� ' <br /> ��- � /�If�P ' CITY/TOWN <br /> Owner's Name �� ��},� e Phone <br /> Address H k <br /> as;?- 41V ex e <br /> • �� C-ity _. <br /> Contractor' s Name AJ License# -Phone <br /> IS CERTIFICATE OF WORK�AAN'S C,0mftNS-ATI.0112 INSURANCE ON FILE WITH SJLHD? YES JCC 11110 <br />�.. �, - a. ._ _ - _.�,.�_ �:,_ _ _ter.- _ ,-� �__—=-•�—..�.—.� . _ _. <br /> TYPE`"`0' W�Q�K(Check).-`�„ N>wkl 1r7E�CC�`�'D'EE�E�V`C�r �C �fDITII}� , DESTRUCTION�`�_ ��.. <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP Ii NSTALLATION Up PUMP REPAIR 0 PUMP REPLACEMENT E) <br /> DISTANCE'TO•,NEARE,ST----`-SEPTIC=TANK; '7 N' <br /> k-. SEWER LINES PIT PRIVY <br /> SEWAGE DISP;OSAL�FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTAft`ATION:4,1!N- ;-Cbhtractor Al V-S <br /> , ' Type.,o Pump <br /> s, <br /> PUMP-R-EPL`AC EM ENT; [J,Sta�te Work: Done <br /> PUMP~REPAIR: <br /> QState Work' Done <br /> DESTRUCTION OF WELL: Well 0.iameter! =Approximate DepthT <br /> -Describe Materia and -Procedure <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 San Joaquin Local <br /> Health District. Home own er-orw--li-censed-age nt•'smsi`gn*td:re-certifi•es-the_follow i.ng:- <br /> "I certify that in the performance of the work for which this permit is issued, I shall j <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." i <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> I DR W�PLOT PLN ON REVERSE IDE f' <br /> ;'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY p� _ DATE 7 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E W,,4FINAL INSPECTION <br /> INSPECTION BY DATE M INSPECTION DAT { <br /> — <br /> 2 / <br /> or 7 <br /> EH 1426 Rev. 1 .77 ® q �� ` 1 1 7 JQ <br />