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. / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: v 1601 E. Hazelton .A.�ce. , Stockton, CA 95205 Permit No.7�1-- ,o/ <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7 <br /> This Permit Ex ires 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 /> ,_oanuin County Ordinance 'No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ojjptS'oo W,.97 tfjAiI,&A/ ,�� CITY/TOWN <br /> Owner's Name lyt- &e I V -ZM �l _ Phone <br /> Address la City G Cf-c rt� <br /> Contractor's Name oeO4gee" "kA- �,T LL,A.� Li cense#3418/2L 3 Phone .36y- /6 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA*dCE OM FILE WITH SJLHD? YES NO X <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION Q PUMP REPAIR C! PUMP REPLACEMENT ❑ _1 <br /> DISTANCE TO NEAREST: SEPTIC TANK t0a SEWER LINES// PIT PRIVY \" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CA <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL CA <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial _Cable Tool v Dia. of Well Excavation 1.2 <br /> Domestic/private Drilled Dia. of Well Casing_T f` <br /> Domestic/public Driven ry - 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 INSTALLATION: Contractor „ ,•,c =LL.. ,y h <br /> r_ <br /> Type Of Pump_ � - - -- H.P._l <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done_ _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 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 FOR A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE C�o--p� DATE: / 2 -7 <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_Z DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� DATE � L_-7 INSPECTION BY, y DATE <br />,EH 1426 Rev_ _12-7-7 -- - /� � I /7A '2M <br />