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! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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(rJ--� " <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application i's '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. <br /> EXACT STREET ADDRESS 3Q S VlIa CITY/TOWN T , <br /> Owner' s NameLi <br /> '# S 6 t A S/O U CiQ r Phone 40--3 93/ <br /> Address 3d a7 City . dlzu <br /> Contractor' s Name GIAA1C. WtCLF -ft License# Phone 2-^� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH-SJC D? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK /60't'SEW.ER LIN£JFL!�(J! PIT PRIVY <br /> �.� SEWAGE DISPOSAL FIELBFZOO,! CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY <br /> LINfi6ohIVATE DOMESTIC WELL'S- ldn, PUBLIC DOMESTIC WELL �---� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavatio <br /> Domestic/private Drilled Dia. of Well Casino S Je <br /> Domestic/public Driven Gauge of Casing S <br /> Irrigation fnvel Pack Depth ofwGrout Seal I d <br /> Cathodic Protection Rotary Type of Grout 8 E%JrdNJf <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done imn accordance: <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 signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I ,shallm- <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL. CALL FORA GROUT INSPECT-ION PRIOR TO ROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE: co <br /> DRAW PL L N ON REVERSE SIDE <br /> FOR 5EPTRTMENT USE ONLY <br /> PHASE I Ar <br /> APPLICATION ACCEPTED BY 4AV DATE CEJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE=/ � INSPECTION BY ! DATE__ _ - 7C� <br /> EH 1426 <br /> -Rey-12-77 1/78 2M <br />