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A 5AN JIJAQU1N LOCAL HLAL I H U15 1 HIL! <br /> FFICE USE:- 1601 E. Hazelton .Ave� ,. Stockton, CA 95205 Permit No.Zq_76 a 1 <br /> Telephone: ' ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/7_a 9_7S' <br /> This Permit, Ex i res 1``Year 'From Date- Issued <br /> 9 Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local health District for -a. permit to construct <br />; and/or install the4work herein described. This .application is made in compliance with San <br /> County, gr�nance r;wo •:1862 and a Rules and Regulations .of the San- Joaquin-.Local Health <br />, District. <br /> EXACT STREET 'Ad SS � ,t/� 1J4 Xn <br /> .41« /`::� CITY/TOWN�� J�j <br /> Owner,-"s Name` ' Phone & 7J <br />.Address ry -% ' . i z,�.�-ci ,�1 <br /> . ' "., City <br /> `�� %� �S Li cense � _p Phone <br />' Contractor's Name- // - <br /> IS CERTIFICATE OF WORKMAN'S CO-11PENSATIO'N I111SURAINCE ON FILE WITH SJLIiQ? YES L,-" 140� <br />' TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP <INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> F ' <br /> DISTANCE TO NEAREST: SEPTIC{ TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Domestic/public Driven w . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical Surface Seal Instal ed by: ^ <br />', PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br />! PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Fetate Work Done . <br />'DESTRUCTION-OF' WELL:-" 'We11-Diameter Approximate De`ptW ` _ 1 <br /> Describe Material- an Procedure <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 , 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 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEQ -TITLE:_ <br /> DATE: I/-�77- 7� <br /> DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEP RTME T USE ONLY <br /> PHASE }I , <br /> APPLICATI'ON ACCEPTED BY - DATE // " Rl <br /> ADDITIONAL COMMENTS: <br /> , . PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'INSPECTION BY DATE INSPECTION BY DATE/-s---]y <br /> EH 1426 Rev- 12_77 _ 1 l7811 2Mr <br />