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SAN JOAQUIN -LOCAL HEALTH DISTRIrT 1 <br /> FOR OFFICE USE: 160. Hazelton .Ave.,, Stockton, CA ,5205 Permit No.,? �Z,/6p <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -3-j-2.,f- <br /> This <br /> ,9This 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 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_4 "1 e�' MMPI MS14' CITY/TOWN S7UC1l TdQ- <br /> Owner's Name C3iQQ.UJy'1.fS '7 SRQ��' Phone 49-7 <br /> Address 43:20 r P-X,4-- /13-6 VdVi7k W2 Z91J WA city_S7—OC',,CTCJ/V <br /> Contractor' s Name CL Pek C b)CLL f4EgU Ip, Li cense# 6 Phone_4 2 <br /> IS CERTIFICATE OF WORKMAN'S CCIMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION 0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK //)0� SEWER LINES PIT PRIVY G <br /> y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER e <br /> • PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> + Industrial Cable Tool —Dia. of Well Excavation_WF7IZ� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Is I <br /> 'LDomesti c/publ i c Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection ::j�otary Type of Grout C C- -' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst al d b• : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 /> laws of California. " <br /> I WILL CALL FO_R -A G)�EI�1T6lSPCTION PRIOR TO GROUTING AND A FINAL INSPECTION. ll <br /> SIGNED :�.,�. `� TITLE: o w�eA DATE: <br /> DR W PLOT PLAN ON REVERSE SID1=��� <br /> FOR DEP RTMENT USE ONLY <br /> PHASE_ I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE JI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE_ INSPECTION BY DATE_ --r-z-fy <br /> EH 1426 Rev. 12-77 - 1/7JP­`2M <br />