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' SAN JOAQUIN LOCAL HEALTH DISTRICT �` Q <br /> OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, CA 95205 Permit No. 79-/x-10 ._ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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/o+ 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. �0 (,6ve�j <br /> EXACT STREET ADDRESS d� W e v .,+ S� ,e r CITY/TOWN <br /> Owner's Name 4,03 Phone o9-Z <br /> Address City . <br /> Contractor' s Name s a /r C� r.'� Li cense# ,R 779_y_7 Phone �"3�3� <br /> IS CERTIFICATE OF WORK?IAN'S C0.1IPENSATIO'N INSURA111110E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTIONC2 <br /> WELL CHL RI <br /> Q WELL ABANDONMENT U OTHER Q _ -- <br /> PUMP INSTALLATION„' PUMP REPAIR❑ PUMP REPLACEMENT [1 J <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 /> ly 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 Installed by: <br /> PUMP INSTALLATION: Contractor ARE S 7 L�� �� i�7'-1Z tc 4C <br /> Type of Pump U H.P. <br /> PUMP REPLACEMENT: j] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter `( Approximate' Depth <br /> Describe Mate'rial and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in acro ante <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 issued, 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 CA L FOR A GROUT INSTXCTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 7� <br /> (DffAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> EH 1426 Rei . 12-77 - 1/78_ <br />