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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE; 1601 E. Hazelton Ave. ,: Stockton;-.CA 95205 Permit No. - <br /> Telephone-: (209) 466- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued b l3 -� <br /> (Complete In Triplicate') ,fro eons <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 Ordinance No. 1862 and the Rules and Regulations -of the San Joaquin'Local Health <br /> District. 1 /�1 rtrer�oe01 <br /> G o <br /> EXACT STREET ADDRESS '04:5 Sa CITY/TOWN <br /> Owner's Name Mp, FLe Y o p u l� F_S Phone - apao <br /> Address 3 63 G r- o n p� City." 0 AJ. .: <br /> Contractor;s Name kALa v i c 14i <br /> �tL C3R! Lei hi G License#34Stia.3 Phone 1 47� <br /> IS CERTIFICATE ,OF WORKIIAP41S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF�WORK (Check) : NEW WELD DEEPEN ❑ RECONDITION ❑ DESTRUCTION[n <br /> WELL CHLORINATION p WELL'ABANDONMENT 0 OTHER � m <br /> PUMP INSTALLATION, PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TA Wbr°F- SEWER LINES.�J6PAC PIT PRIVY 06PF- <br /> SEWAGE ,DISPOSAL FIELDA)i wr ,CESSP L/�EEPAGE PIT &0.ACOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL °OL PUBLIC DOMESTIC WELL 140tele <br /> INTENDED USERk. TYPE OFI'WELL CONSTRUCTION SPECIFICATIONS <br /> Industria"1 -- _:-- �rable,:ToolDia. of Well Excavation / tf� l <br />__,��Domest-i C/pri v a t e � .Dri 11 ed Dta. of Well Casing 1771- <br /> Domestic/public -, ¢.,D,ri_ven` Gauge of Casing / o-,4... <br /> Irrigation r Gra£v01-Pack44t Depth of Grout Sea 5 =-'co - - <br /> Cathodic Protection ki Rotary ' Type of Grout a_t^M Al T <br /> Disposal, Other.:- Other Information <br /> Geophys i cal�'.'-.� --` -� N --_- - <br /> �- Surface Seal Installed b I L. <br /> PUMP INSTALLATION:-.)=-Contractor ��,� r.�, ' ',���c <br /> 1 Type of Pump L R G. Aw P e } <br /> P. <br />'UMP REPLACEMENT: ]State Work Done" <br /> LUMP REPAIR: Q State Work Done <br />)ESTRUCT°ION OF WELL: Well Diameter 4 Approximate Depth <br /> d Describe Material andmProcedure <br />[ hereby .certify that-I--have -prepared this 'applica.tion and that the wariC will be done in accordance <br /> with San-Joaquin <br /> . .County _Qrdinances .State- Laws ; 'and Regulations of the�San_Joaqufn Local. <br /> lealth District. Home owner or. licensed agent' s signature certifies the following: <br /> "I certify that in ,the_per..fomrmance of mthe work-for which thrs -permit-is issued, I"s all �" i <br /> not employ any person in such manner as to become subject to Workman's Compensation { <br /> laws ,of California. ". P V < , <br /> WILD CALL FOR A GROUT INSPECTIONAIOR TO GROUTING:AN< D A FINAL`- INSPECTION. ' <br /> SIGNED ' <br /> TITLE:L'4 DATE: <br /> D PL NON REVERSE SIDE <br /> FOR DEPARTMENT ---SE ONVY <br />`RASE I h�Y�� <br />,PPLICATION ACCEPTED BY � �p�--��� DATE �r/ 3-- �9 x <br /> DDITIONAL COMMENTS:' ,n� a --- <br /> ' PHASE II GROUT INSPECTION <br /> PHASE IIIFINALINSPECTION <br /> NSPECTION BY DATEINSPECTION BY DATE <br /> H 14 26 Rev. 9/78 kq17R 2 . ; <br />