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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR F'FICE 'USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-7`l 4a I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued qtr 7_7y <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 Health <br /> District. <br /> VACT STREET ADDRESS 3737 WEST 11TH STREET CITY/TOWN TRACY <br />)(Owner's Name HERBERT F. AND EULA D. SWEET Phone 209-835-1419 <br />}AddressCity TaACy-, GAT.IF .. <br /> XContractor's Name mT4ZLicense# Phone <br /> IS CERTIFICATE OF WORKMAN'S C0.11PENSATIO'1 It3SURANCE ON FILE WITH SJLHD? YES 1110 <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN ❑ RECONDITION ❑ DESTRUCT10 ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 9 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLA E NT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY G] <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER --f <br /> PROPERTY LINE„-...PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'E <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing___ <br /> Domestic/public Driven Gauge of Casing --X <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 /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: . 14State Work Done <br /> DESTRUCTION' OF 'WELL:- Well -Diameter Approxi ate Depth <br /> Describe Material and Procedure i; <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 issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California.” <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />. SIGNEDJXN7TITLE: -- DATE: YT-j3 -72 <br /> DRAW PLOT PLVN ON REVERSE SIDE <br /> FO,Pp DEP ITMENT USE ONLY <br /> PHASE I Z Z e-> <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> EH 1426 RPv_ 12-77 _. �l/78 2M <br />