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SAS' jOAQUIN-LOCAL• HEALTH -DISTRICT O ' <br /> FFICE USE: 1601 E azelton Ave. , ,Stockton, CA 9 5 Permit No. '79-7D-3 <br /> Telephone: (209)'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/,- a,7- 99 <br /> This Permit Expires 1 Year From Date Issued <br /> •omp ete In Trip icate <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 Ordinancelo. 1862 and -the Rules and Regulations of the San Joaquin Local Health <br /> District. .1, E <br /> EXACT STREET ADDRESS �oZ W G�i(.� t P�-� e i CITY/TOWN <br />,Owner's Name `,k Phonal5'—Fc— L <br /> Address [� //�� City �. <br /> Contractor's Name �D_/_ So� _z License#33g-4.7/ Phone�Q3s <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOl INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : .NEW WELL[] -DEEPEN ❑ . RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATIONWELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION �. PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK; ' SEWER .LINES PIT PRIVY t <br /> SEWAGE DIST SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LTNE"- PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL s <br /> INTENDED USE '..TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS n <br /> Industrial Cable Tool Dia. of Well Excavation U <br /> _Domestic/private .. Drilled Dia. of Well Casing <br /> Domestic/public , Driven -- Gauge of Casing ' <br /> Irrigation ;Gravel Pack Depth' of Grout Sea <br /> Cathodic Protection Rotary Type of Grout .f- <br /> Disposal Other Other Information— <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4,;c4,8.— H• L <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: -❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mate.rial -and Procedure <br /> I hereby certify that I have prepared this, application and that the work will be done in accordanck <br /> with San Joaquin County Ordinances , Statet:L•aws , and Rules and Regulations of the San Joaquin Local <br /> flealth 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 INSPEC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: a DATE: (o —2—v -17 <br /> (DRAW PLUTLVN ON REVERSE SIDE <br /> FOR DEPARIMUT USE ONLY : <br />,PHASE I <br /> PPS LIGATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINA SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a <br />-n 'Ane n_.. ,n 1� l /7R 7M <br />