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SAN JOAQUIN LOCAL HEALTH M TRICT <br /> FFICE USE: :1601 E. Hazelton Ave. , Stockton, CA 95205- Permit No. <br /> Telephone: (209)1' 466-'6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPP Date Issued Z _zf <br /> PERMIT . <br /> A (f:omplete In Tri i <br /> Q" ,�Tg , r"Po p1 nate) - , <br /> �,�Z2 -t-vo 3 Z = x., <br /> Application is hereby ma -de 'to the San Joaquin Local Heaith` Distri•ct.. for a�permit to construct <br /> and/or instal ] the work herein described. This application is made an compliance with San <br /> Joaquin County Ordinance Nod 1862 and the Rules and RegUlatiohs of the San Joaquin. Local . Health <br /> District. 6pQ�fAov eo, e, l /Bab �G-�i�ncai� <br /> 4 - <br /> EXACT STREET ADDRESS <br /> Owner's Name <br /> ._.°� CITY/TOWN <br /> Phone <br /> Address .". r <br /> - City , <br /> f Contractor's Name ,rte License .S7S3-Phone _ sl <br /> IS GERTIFICATE 'OF WORKtMAN'S-COMPENSATION INSURANCE ON FILE WITH-SJLHD? . YES NO � <br /> TYPE OF. WORK (Check) : NEW WELL❑ _ DEEPEN Q� RECONDITION ; _ <br /> WELL CHLORINATION 0 WELL ABANDONMENT d DEOTHERTf� N <br /> PUMP INSTALLATION PUMP REPAIR 0- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DINES IPIT PRIVY <br /> SEWAGE DISPOSAL FIELD % ' ..CESSPOOL/SEEPAGE Pi OTHER <br /> PROPERTY LINE - PRIVATE DO EST,IC WELL PUBLIC DOMESTIC WELL <br /> .INTENDED USE <br /> TYPE OF.WELL. CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia:` of We 1 Excavation <br /> Domestic/private <br /> Drilled Dia. of Weil, Casing <br /> - mest'i ubl i c - . �` . � Driven <br /> Gauge%of Casing <br /> Irrigation' Gravel Pack Depth .of Grout Sea <br /> a rotection —Rotary T <br /> DisposalOther y Type .of Groat <br /> .Geophysical — Other Information <br /> PUMP INSTALLATION:- Contractor / <br /> Surface.=Seal InstaEed jy <br /> •. . �- Type o�, Pump <br /> PUMP REPLACEMENT _ H.P.--� f <br /> State Work Done <br /> PUMP REPAIR: <br /> ❑St ate Work Done *4 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth - <br /> Describe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the•work will be done in accordance <br /> with San Joaquin. County Ordinances , State Laws , indIRules-and Regulations of the- San Joaquin, LocaT <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify-that in the performance` of the' workifor which this permit :is issued, I shall <br /> not employ an � <br /> p y y person in such manner- as to become ,subject to Workman's Compensation <br /> laws of Ca'Tifornia. " i <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAINSPECTION, <br /> SIGNED C �1'mc�� ���7, � <br /> ' ITLE: DATE:_&*d r <br /> DR W PL T P NON REVERSE SI E <br /> PHASE I s F R DEP RTMENT USE ON Y <br /> PPS^LIGATION ACCE.PTED�BY L z <br /> kDDITIONAL COMMENTS: DATE S 3-7 i <br /> 'PHASE II GROUT - SPECTION <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br />:H 14 26 Rev. . 9/7$ INSPECTION BY DATE 7—/3-' <br />- -- m�d q/7R 2M Y.] <br />