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. SAN JOAQUIN LOCAL, HEALTH DISTRICT permit No. 4 'S <br /> FFIC� USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 <br /> Telephone: {209) 466-6781 pate Issued 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres l .Year From Date Issued <br /> Complete In Trip icate <br /> )plication is hereby made to the San Joaquin Local Health District orin capermncetwithnSanuct <br /> applicatmadeion id/or install the work herein described. This app <br /> �a uin County Ordinance No. 1862 and th Rules and Regulations of the San Joaquin Local. Health <br /> q . <br /> istrict. 8►SfD � CITY/TOWN ? <br /> XACT STREET ADDRESS Q9 0M64K5 <br /> Phone4A - <br /> wner's Name City - <br /> ddress <br /> License# Phoneme 2 <br /> ontractor' s Name G,q <br /> 'S CERTIFICATE OF WORKMAN'S colcIPENSATIO'N I';SURANCE Ofl FILE WITH SJLHD? YES NO <br /> �YP-E_ OF WORKS(check)-: �NEW�-WELL�1 = DEE-PEN Ei-�--'RECONDITIMENT Cl OEST OTHERFN <br /> I� �--=----�f <br /> WELL CHLORINATION j] WELL ABANDON <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT LTJ <br /> )ISTANCE TO NEAREST: SEPTIC TANK� BTSEWER LINESESSPOOL/SEEPAGE PIT YPIT OTHER <br /> SEWAGE DISPOSAL FIELD /6— <br /> a <br /> PROPERTY LINE -. PRIVATE D GESTIC WELL PUBLiC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing.," <br /> Domestic/public Driven Gauge of Casing_^ O <br /> --Irrigation _Gravel Pack Depth of Grout Seal_ FT i <br /> cathodic Protection _ Te of GroutRotary Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: fn State, Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> -DESTRUCT-ION-OF,W.EL-L:--�Wel1•-Diameter- -- - - - - � '-ApPraximate.Depth - -.---r <br /> Describe Material and race ure <br /> I hereby certify that I have prepared this app1iz a-tion and that the work will be done in accorc <br /> with San Joaquin County Ordinances , State=,Caiws, and Rules and Regulations of the San Joaquin Lc <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 /> laws of California." <br /> I WILL CALL F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> D: <br /> TITLE: DATE: 3' <br /> SIGNE <br /> DR PL P NON REVERSE SIDE <br /> F D P RTM N USE NLY <br /> PHASE I DATE A <br /> APPLICATION ACCEPTED BY 4 --k <br /> ADDITIONAL COMMENTS : PHASE II FINAL INSPECTION . <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION B C ATE /D 7--r, - <br /> P-416 ..J..... GAJ.. <br />