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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FFICE USE: 1601 E. Hazelton Ave. , 'S.tockton, CA 95205 Permit No. _ 7j-/ 7J <br /> Telephone: (209) 466-6781 r <br /> APPLICATION F0R' t CONSTRUCTION OR PUMP PERMIT Date Issued ?-V- 7,'� <br /> This <br /> -V- <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 fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oaauin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS � Al ,ygZ _ CITY/TOWN 'psi d i <br /> Owner' s Name .RP;- J'1A1 Phone^S�/� 1s <br /> Address �� 7r.3 S�.eso r .� City �A7 <br /> Contractor's NameLi cense# Phone �� <br /> IS C-ERTIFI°CAT£OF WORKMAfl-'-S COMPENSA-rl0i'I-INSURA"ICE-0Nl-F`I'L-E-WITH—SJLHD?—YES—NO" <br /> TYPE OF WORK (Check) : NEW WELL DEtPENEO RECONDITION ❑ DESTRUCTION[J ' <br /> WELL CHLORINATION p' WELL ABANDONMENT ® OTHER 0 N <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES/10-i PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SW PAGE PIT OTHER N : <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL4&gE_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF#WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _� �Cable Tool Dia. of Well Excavation iv <br />'Domestic/private Drilled f Dia. of Well Casing o� <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout &�i <br /> Disposal , Other Other Information <br /> Geophysical _ Surface Seal Installed by: <br /> PUMP INSTALLATION: • ContractorL rr1 r�cAl <br /> Type of-1p 0 o H•.P. .� <br /> PUMP REPLACEMENT: []State Work Done,< 1 <br /> PUMP REPAIR: QState Work e{ + <br /> ' 3 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Ma'teriaT--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 owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance oft,'ihe work for which this permit is issued, I shall <br /> not employ any person in such manner, as.kto become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GRWT INSPECTION PRIOR TO! GROUTING AND A FINAL INSPECTION. <br /> SiGNEO TITLE: •^ 7c.c_� DATE: -s � - <br /> •T -' DRAW PLOT PL N ON-REVERSE-SIDE - w ,, ..- . <br /> FOR DEPARTMENT USE ONLY -m - <br /> PHASE I Z& <br /> PPLICATION ACCEPTED BYZz 'L< . DATE 3 <br /> ADDITIONAL COMMENTS: 41 <br /> PHASE_ II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - 7 INSPECTION BY DATE .3� �,,�y- <br /> CLI 9A7G n,... 1r] Z7 '//v / 1 /7S2 ?M <br />