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74' <br /> SAN JOAQU,IN LOCAL HEALTH D1SIkIC1 .1� <br /> FOR OFFICE USE: 1601 E. zel'ton Ade. , Stockton, CA K 3 Permit No.7f_,si <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,& 2,.9— <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construcil <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 l � �X` CITY/TOWN <br /> Owner's Name iS Phone -T <br /> Address �� City <br /> Contractor's Name p License# ,� n,/� Phone �� a- 1103 / <br /> IS CERTIFICATE OF WORKMAN'S C MIPENSATI.Ot INSURANCE ON FILE WITH SJLHD? YES r t0 <br /> TYPE OF WORK (Check) :, NEW WELL`C- DEEPEN (] RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ • WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />(DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESS�P OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL , <br /> INTENDED USE ✓ TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled. Dia. of Well Casing 7, 2 <br /> Domestic/public Drivp6 - Gauge of Casing ?Z44-, <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection � otary Type of Grout <br /> Disposal Qther Other Information v <br /> Geophysical Surface Seal Installed <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: C]State Work Done <br />°UMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> Q hereby certify that I have prgpared this application and that the work will be done in accordanc <br /> lith San Joaquin County Ordinances , State Lbws, and Rules and Regulations of the San Joaquin Local <br /> 4ealth 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 lifornia. " <br /> I WILL ALL FOR A GROUT QPECTION,,PRIOR Tb GROUTING ANaA FINAL INSPECTION. <br /> T <br /> /iIGNED � <br /> ,7 <br /> DR W� L L N ON'RE .ER IDE <br /> R DEPARTMENT USE ONLY <br /> 1HASE I <br /> APPLICATION ACCEPTED,BY Q� � � DATE��-� <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE 1 .219 INSPECTION BY4Qf DATE, ?o=E� <br />•• . .n.. p . � -ACJ • I I n `..t <br />