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F _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r =FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �aJ- <br /> J <br /> r (complete In Triplicate) ` <br /> Application is hereby made to the San Joaquin. Local HealthiDistrict' for a 'permit to 'construct <br /> and/or i.nstall the work herein described... This- appl.ication. is made in compliance with San <br /> Joaquin County Ordinance No! 1862 and the„ Rules and Re i ns of :the. San Jo gain Local Health <br /> District. �d/Vi 4- k7rvar�r4 �r/,�. 57 ''--JJ j� � <br /> EXACT STREET ADDRESS ,S ' /� 6 CATY TOWN !l'e <br /> / <br /> Owner's Name i C"t Phone <br /> Address I <br /> Al/0-�d�s' City q5"y <br /> Contractor's Name PZ O License#���--Phone �_ _2 k5 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUM.110E ON FILE WITH-SJLHD? YES No <br /> TYPE OF WORK (Check) : - NEW WELL L DEEPEN D RECONDITION [3 DESTRUCTIONC3 <br /> WELL CHLORINATIONWELL ABANDONMENT Q OTHER f:] <br /> PUMP `INSTALLATION: PUMP REPAIR 0- RUMPOEPLACEMENT'ET V <br /> DISTANCE TO NEAREST: : SEPTIC TANK SEWER LINES, - -PIT- PRT'VY' <br /> i SEWAGE -DISPOSAL IELD CESSPOOL/SEEPAGE!PI7-- OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> — INTENDED USE TYPE OF -WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing <br /> _ <br /> Domestic/public_ Driven Gauge of Casing' <br /> Irrigation Gravel Pack Depth of Grout, Sea <br /> Cathodic Protection Rotary Type of Grout. . <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed by:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor .4,C p z!, <br /> Type 6f Pump S - H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> 'PUMP REPAIR: ❑State Work Done <br /> !DESTRUCTION OF WELL: Well Diameter '-� <br /> Approximate Depth <br /> Describe Material an2 Proce ure <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 'sibnature. 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. " f <br /> I WILL CALL F@R A GR UT INSPECTION P IOR TO GROUTING AND A- FI L INSPECTION: <br /> SIGNED .TITLE: DATE: -,� -9 <br /> a DR PLT PLAN ON REVERSE SIDE "-. <br /> PHASE IFOR DEPARTMENT USE ONLY �Y <br /> TP—PLICATION ACCEPTED BY � _ <br /> ADDITIONAL COMMENTS: DATE Z. <br /> VL!L- <br /> PHASE Ii GROUT INSPECTION PHASE II 'FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-Z2_-7:2 <br /> 14 26 Rev. 9/78 g�, � ' � , �� 9/7$03 2M <br />