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_ SAA JOAQUIN LOCAL HEALTH DISTRICT <br /> jOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '71- 10 2L_ <br /> Telephone: (20 9) 466-6781 .� :* P. , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -(Q--71 <br /> This Permit <br /> Expires 1 Year From Date Issued <br /> Complete In Triplicate . . a <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 /> Joaquin County'Ordinance No. 1862 and the Rules and Regulations a the San Joaquin Local Health <br /> District. <br /> EXACT ,STREET ADDRESS J f CITY/TOWN <br /> Owner' s Name Phone <br /> Address City . <br /> Contractor'Is NameN R 4 . -,Licensee Phone <br /> IS CERTIFICAT£11A,' <br /> OF WORKtS C'OMPENSATIO"a INSURANCE ON- FILE WITH SJLHD? _ YES NO <br /> TYPE OF WORK (Check) : NEW WELL- DEEPEN Q RECONDITION ® DESTRUCTIONED <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 - <br /> PUMP INSTALLATION [] PUMP REPAIR 0 PUMP REPLACEMENT [I <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-''�f CONSTRUCTION SPECIFIC O <br /> Industrial Cable`Tool Dia. of Well Excavation 1 <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 <br /> Geophysical Surface Seal I;n.sta1 I ed b ✓ <br /> PUMP INSTALLATION: Contractor <br /> -Type of Pump H. . <br /> b s <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done. <br /> DESTRUCTION OF WELL: s Well Diameter �',.,r 'Approximate Depth . <br /> Describe Material an `..Proce ure - <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,taws, 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 is permit is issued, I shall <br /> not employ any person i.n such manner as to bece-subject o Wo n's Compensation <br /> laws of California:" r �. �_- ----- 1. -'~`� <br /> I WILL CALL R GROUT INSPEC NIPRIOR TO GROUTIN ND_`A- A I P I <br /> F <br /> jSIGNED ` a - TITLE: <br /> DR W.-P_L- T�-PL- N ON`- E" SIDE- -- -_'_ <br /> -" <br /> FOR DEPARTMEWPM,ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE .--- <br /> ADDITIONAL COMMENTS: f " <br /> PHASE II GROUT INSPECTION PHASE IIT FINA_ INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE. -- <br /> [CU znoc n,... 10 7-7 y - _ 1/78 2M — <br />