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SAN JOAQUIN, LOCAL, HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 y- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G- <br /> '(16omplete In Triplicate) <br /> I Application is hereby made to the San Joaquin Local, Health District .for a permit to construct <br /> k .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 CITY/TOWN <br /> F <br /> -Owner's Name Y' d �� Phone <br /> Address City - <br />� Contractor's Nameilb P V IA12 1 License Phone <br /> .IS CERTIFICATE'OF_WORKMAN'S COMPENSATION IN,SURA^CE ON FILE WITH SJLHD? YES N 0��� <br /> E TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER El <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . .. ., ._. PIT"PRIVY �' r <br /> SEWAGE DISPOSAL FIELD CESSP Ol./SEEPAGE PI�� OTHER <br /> PROPERTY LINE.- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> .$-,INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -4 Cable Tool Dia. of Well Excavation o -ee_c:1.—, <br /> j,!t-Domestic/private milled Dia. of Well Casing c-, <br /> Domestic/public Driven Gauge of Casing G. <br /> r Irrigation �— Gravel Pack Depth of Grout _§e—al_ <br /> Cathodic Protection `� otary Type of Grout (ter <br /> Disposal Other Other Information - <br /> Geophysical urfac Sea Installed by: IAVZe�_5 <br /> PUMP INSTALLATION: Contractor /f/G&y r 2200. d <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State WorkiDone <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �_ Approximate Depth <br /> Describe Mat7eri&l and Procedure <br /> I hereby certify -that I have prepared -this application and that the work will be done in accordant, <br /> with San ,Joaquin County Ordinances , State Laws , and Rules and . Regulations of the San Joaquin 0e— l <br /> Fealth 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 /> 1 .1 WILL CALL FOR GROUT INSPECTION PRIOR TO GROUTING AND A' FIN L INSPECTI N. <br /> SIGNED _ T TITLE: I„ DATE: <br /> - DRAWPL L N ON REVERSE I E <br /> R DEP lRTMENT USE ONLY, <br /> PHASE I <br /> APPLI.CATION ,.ACCEPTED BY Ar� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE III FINAL INSPECTION <br /> INSPECTION BY . cry DATE INSPECTION BY �M DATE tib. 7 <br />!'EH '14 26 Rev. 9/78 - _ <br /> ._ . 9/-78---' -2M <br />