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SAN JOAQUIN LOCAL HEALTH DISTRICT_ <br /> FFICE USE: �11601 E. Hazelton Ave-,, :Stockton, CA 95205 Permit No. <br /> ®o Telephone: (209) 466-6781 <br /> Date Issued_2_S--?1L <br /> ':APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> li This Permit Expires 1. Year From Date Issued <br /> Complete InTriplicate <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 /> ,Ioapuin County Ordinance No.. 1862 and the. Rules and Regulations of the San Joaquin. Lotal Health <br /> District. .Sf�� iro•J� rs <br /> TR T ADDRESS CITY/TOWN <br /> EXACTS EE <br /> ' <br /> Owner's Name nm a 13 3. <br /> Phone — YT -- <br /> Address City <br /> Contractor' s Name m E. Cebb ~� icense#361412 _ Phone 4 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO-N INSURANCE ON FILE WITH-S.JLHD? YES- NO <br /> TYPE OF WORK (Check) : NEW WELL EJ • DEEPEN ❑ RECONDITION [] DESTRUCTION.❑ to� <br /> WELLCHLORINATION ❑ ,WELL ABANDONMENT 0: OTHER ❑ <br /> .PUMP 'INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: :SEPTIC TANK L1 -,*SEWER LINF���//��F- PIT PRIVY ' <br /> SEWAGE DISPOSAL�FIELD /w!,,;D,i•€SSPOOL/SEEP AT�- � 0THER <br /> :.PROPERTY LINE PRIVATE' DOMESTIC WELL _PUBLIC DOMESTIC WELL <br /> . INTENDED USE TYPE OF WELL" CONSTRUCTION- SPECIFICATIONS <br /> IndustrialCabl-e Tool Dia. of Well Excavation <br /> X omesti c/private Dri]led Dia. of Well, C,atli ng � <br /> F Domestic/public —Drive' <br /> riven - Gauge of Casing f: <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' Rotary Type of Grout _ . : <br /> DisposalOther Other Information � � . <br /> ,1 <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: OContractor <br /> Typ f Pump H.P. <br /> PUMP REPLACEMENT: ED State Wor <br /> PUMP REPAIR: <br /> ]St State Work Done <br /> DESTRUCTION OF WELL: !Well Diameter Approximate Depth, <br /> �' Describe eria and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County 0"rdinances, State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Homeowner 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.G UT INSPECTION PRT TO UTING AND AF NAL INSPECTION. <br /> �: SIGNED s�� �- TITLE: - .� <br /> DATE: s 7 <br /> DRAW'P `0 PL N ON REVER E SID <br /> E <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE I? r c <br /> _APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY��L�I`�=�, DATE '31DINSPECTION BY DATE <br /> 10"8 .2M <br /> I:N 11171, L QAl! 19_77 <br />