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Gu aA+erl <br /> ou°`l A''f woT SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT i..date Issued -/S-? <br /> {complete In Triplicate') ti <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-its made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local ealth <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name "Z 34MPhone <br /> Address. a.Ix City ., <br /> Contractor's Name License#jf-7),,r7 Phone _ 4 7 6 <br /> IS CERTIFICATE OF WORKMAN S1,4,AENSATION INSURANCE ON FILE'WITH SJLHD? YES Igo <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ ��RECONDITION ❑ DESTRUCTI;ON <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP ,.INSTALLATION •CJ PUMP REPAIRCO PUMP REPLACEMENT E3 ,-- <br /> DISTANCE <br /> "`DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. UA <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCT.ION !;SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing w <br /> Domestic/public Driven Gauge of Casing <br /> �X _Irrigation Gravel Pack Depth of Grout Sem-� <br /> —Cathodic Protection -4- Rotary • .' . Type of Grout <br /> Disposal —, Other Other 'Information <br /> -Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor - <br /> Type 'of Pump H. o <br /> PUMP REPLACEMENT: 71 State Work Done i w <br /> PUMP REPAIR: ®State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Materia7—a-n-a 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 iss•ued, '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. I E TIO RIOR TO GROUTING AND..A`FINAL INSPECTION;. <br /> SIGNE TITLE: DATE: �o <br /> PLOT PLAN ON REVERSE..SIDE <br /> PHASE I <br /> FOR DEPARTME T USE ONLY <br /> -- - - <br /> AT—PLICATION' ACCEPTED BYZ,(2 , �,.., DATE // 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION pHA E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE I <br /> EH 14 26 Rev. 9/7 1 - <.g/s 2 <br /> . r �_ - _ w _ W _ . 78 <br />