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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave Stockton, CA 95205 Permit No. ?g_1jgl <br /> Telephone: . (209) :466 -6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date Issuedf2 L <br /> This Permit Expires 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 instal"1 !lthe work herein described. This app"lication' is "made. in compliance with San" <br /> �_oanuin County"erdinance No. 1862 and the Rules and Regulations of the San ;Joaquin.. Local Health <br /> EXACT STREET ADDRESS u 6,�r __ : - - aTC �=�. . . w: CITY/TOWN ►VA <br /> T4. i � <br /> Owner' s Name <br /> Address L7 © N �C} City.. -ST'S-c •�c _+,� <br /> Contractor's Name -S '7'+4 nJE:.* e L,a; 1 o License# Phone 4NL---0-S <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q " RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION d WELL ABANDONMENT ®---OTHER 0 <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC_IFI_C_ATIONS <br /> Industrial- Cable Tool Dia. of Well Excavation w4-1 <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 f Type of Grout <br /> Disposal' Other Other Information <br /> Geophysical '' Surface Seal� Installed by_: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H, . <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -7-5 <br /> Describe Material and,,P.:r..ocedure 4' coh <br /> €'icrZa W Ad <br /> I hereby certify that I have prepared this application and that the work will be done in accordannZl <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 /> Pot employ any person in such manner as to becb�-6subject to Workman 's Compensation <br /> laws of California, a ; <br /> I WILL OR' A GROUT NSPECTION PRIOR TO GROUTIIVG:.AND A FINAL INSPECTION. <br /> SIGNED ev TITLE: DATE: i 2� 7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I OF <br /> 4PPLICATION ACCEPTED BY DATE /1 7 9 <br /> 4DDITIONAL COMMEN _ <br /> PH ROU INSPECTION PRASE III FINAL INSPECTION <br />[NSPECTION BY ATE 9 INSPECTION BY DATE//-'4--99 <br />:H 1426 Rev. 12-77 __ 1 /7R 2M <br />