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SAN JOAQUIN LOC-ALiHEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave,. ,.. Stockton, CA 95205 Permit No. <br /> Tel ephone: (1209) 466-6781 <br /> Date Issued `11S- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This' Permit. Expires 1 Year From Date .Issued <br /> Complete In Triplicate <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 of the San •Joaquin Local Dealth <br /> District. 1 <br /> EXACT ;STREET. ADDRESS 3, - Z9,. CItY/TOWN' i - 1 <br /> .r <br /> Owner's Name_ 4 �,�/;.� Phone :3 q— 2�3 ,e,� <br /> Address - e teZ_ � City <br /> Contractor's Name , st icense#���. Phone <br /> IS CERT-IFICATE OF WORKMAN'S COMPENSATIO"l I'NSURA"IC ON FILE WITH SJLHD? YES 'd0 <br /> TYPE OF WORK (Check) : NEW WELL Q �-DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ 4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION 0— PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK -PIT SEWER LINES , _PIT PRIVY <br /> SEWAGE DISPOSAL FFIELD ap-,-t CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ,IIPRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ c <br /> Industrial Cable- Tool Dia. of Well Excavation ; - <br /> A., Domestic/private Drilled Dia. of Well Casing �. <br /> Domestic/public Driven - Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ' < , . Other Information <br /> Geophysical � �"`Surface Seal Installed by: _ <br /> PUMP INSTALLATION: Contractor ,� << { <br /> Type of Pump H.P. <br /> I� PUMP REPLACEMENT: C]State Work Done <br /> f,PUMP REPAIR: ❑State Work Done <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth =. <br /> Describe Material ana Procedure N�4. <br />' 4 <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 />-Heal th-Di-stri-ct-- --Home`owner or 1 i censed agent' s s i gnaturO*certi f es-the"'fol 1 owi rig: _- <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 /> r fi. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND 4JINAL INSPECTION. <br /> SIGNED .,, .�v ,cam TITLE: DATE: E <br /> (DRAW PLT L N ON RE RSE SIDE t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE A/- . r %7p <br /> ADDITIONAL COMMENTS : <br /> PHASE II -GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , 3 DATE7 /L12 <br /> Eke 1426 - - Rav- 12-77 l 1/78 2M <br />