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A <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br />;__FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,7� <br /> Telephone: (2O9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued e_ _7_2 <br /> This Permit Expires 1 Year From Date Issued ' 1 <br /> Complete In Triplicate r r <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 mad& iln compliance with. San� <br /> , oaquin County Ordinance No. 1862 and the Rules and Regulations of -the San Joaquin Local . Health a <br /> District. i <br /> EXACT STREET ADDRESS ] �_ _ �Z�, __ CITY/TOWN. <br /> C!}L 0 <br /> Owner' s Name A Phone139-7 19 <br /> Address City p <br /> Contractor's Name LicenseV Phone :7.2,261 -- <br /> ?S CERTIFICATE OF WORKMAN'S COF PENSATION 1NSURAINCE-ON FILE WITH .SJLHD? - Y-ES _ '40— - <br /> TY-PE�OF�`WORK�(ch-eck) ;..;NEW`1�1ELL[�J��bEEPEN I�"-�R�EONDITIaN-[]� DES1`�RUCTTON[� <br /> WELL CHLORINATION p WELL ABANDONMENT n OTHER <br /> �. -..,,--.-- . —PU.MP—I.NSTALLATION,-U._PUMP REPAIR©..._PUMP REF}LACEMENT_5a_ J <br /> si <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 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 Gauge of Casing___„_____ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ k <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: - Contractor <br /> Type of-'Pump H.P. <br /> PUMP REPLACEMENT: [MS'tate-'Work Donee „l ,-e _ <br /> f <br /> PUMP REPAIR: W []State Work Done _- <br /> DESTRUCTIdCOF:WELL: �RWelI- Diameter Approximate Depth <br /> -� Describe Material and Procedure . <br /> I hereby certify that I. ,ha've prepared this application and that the work will be- done in accordance <br /> with San Joaquin CounfyAOrdinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. -Home owner or licen`sed:`agent' s`�signatureTcertifies"the following: <br /> "I certify that in the performance of�the work ,for Whtdh 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." 'k <br /> I WILL CALL FO%A GROUT INS CT PRIOR TO GROUTING AND A FINa INSPECTION. <br /> SIGNED ' TITLE: j DATE:6)_L/:::1 <br /> - ' DRAW PL L N ON REVERSE SIDE <br /> w S FOR DEPARTMENT USE ONLY <br /> PHASE I� k <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> #, : PHASE: II GROUT,,:1NSPECTION PHAS I I INAL NSPE TION <br /> INSPECTION BY, : + °4 DATE INSPECTIONS DATES;-2/-2P_ <br /> EH 1426 Rev_ 12-77 - <br />