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ill /7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1,601 E izelton Ave. , Stockton, CA 9. .i Permit No. 7y-y59 <br /> felepHune:=• (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5-/0- <br /> 72 <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate) t <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 /> Joanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> EXACT STREET ADDRESS 3y,2rP Yt�,Qfir»J��/i �/�/._iL�-��i CITY/TOWN <br /> Owner's Name A/ Phone <br /> Address� City <br /> Contractor's Name,Z ,.` .r,,. /��Q. �j _ Licenset,?,QQWPhone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES �� NO <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL' CHLORINATION 0 WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Z <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ;?-k <br /> INTENDED USE TYPE OF WELL i .• CONSTRUCTION SPECIFICATIONS <br /> In usstrial Cab a Tool Dia. of We Excavation ' <br /> Domestic/private �, Drilled Dia. of Well Casing •6 46;A�9 <br /> Domestic/public Driven - Gauge of Casing d' <br /> Irrigation Gravel Pack Depth of Grout Seal -T71 <br /> Cathodic Protection -Jt6 taryl Type of Grout <br /> Disposal Other' Other Information oei <br /> Geophysical _ Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: (] State Work Done` <br /> PUMP REPAIR: ❑Sta•te Work Done <br /> DESTRUCTION OF WELL: Well biameter 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 accordanc <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 GROUT <br /> //INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDe�.t TITLE: DATE: <br /> DRPLT LAN ON`REVERSE SIDE <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> - —} �IIN�SSP,EEC}TION BY DATE�f� <br /> ... ! J?O1 "y17r `""^ ""`7 &'4'Al � 1 ./1 ;1 rP 1 /'!A 'J M <br />