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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> ``Stockton, CA 95205 Permit No. '7 <br /> F.FICE USE: 1601 E. Hazelton `Ave. , <br /> Telephone: (209} �6fi-6781 Date Issued le- 19-22 <br /> 6 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT _ <br /> .(Complete In'Tri p17 cata) � <br /> Application is hereby made to the San Joaquin Local' Health District for a permit to construct , <br /> Viand/or install the work herein described. This application is made •in -compliance with San <br /> 1Joaquin County Ordinance No, 1862 and the -Rules and Regulations of the -San 'Joaquin Local Health <br /> District. / �'�ko_ 10 <br /> J1 r EXACT STREET ADDRESS /TOWN — <br /> � Cwner's Name Phone _ <br /> Address City o <br /> Contractor's Name License Phone - kI 1 <br /> IS CERTIFICATE-OF WOf:K�tAtd'S CO�iPENSA7Im INS RA^ECE ON FILE WITH SJLHD? YES 0 <br /> � <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN ijT <br /> 'RECONDITION <br /> FDESTRUCTION[, <br /> '.WELL CHLORINAT-ION 0 " WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT ❑ <br /> t - <br /> DISTANCE TO NEAREST: SEPTIC'TANK !!_ SEWER .-LINE$ , p r ,PIT PRIVY -- <br /> SEWAGE DISPSO ALrFIELD t ESL/SEEPAGE PIT —� OTHER <br /> ► PROPERTY LINVO- PRIVA�ESTIC WELLLYA__i-- PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> Industrial,: , Cable Tool Dia, of Well Excavation `� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publJ c _ Driven Gauge of Casing 6a <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic xProtecti-on - Rotary Type of Grout <br /> Disposal Other Other Information --- <br /> -Geophysical Surface Seal' Installed by: <br /> PUMP INSTALLATION.: Contractor <br /> - t - Type of Pump H. :� _ <br /> EPUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: : ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of ,the San Joaquin Lorca' <br /> Health 'District. Home owner or licensed agent' s signature certifies the following: :.r <br /> "I certify that in the performance of the work for which this permit is issued, I shall - <br /> not employvany person in such manner as to become subject to Workman' s Compensation, <br /> laws of California. <br /> I WILL CALL FOR A GBOT AISPKTAN PRIOR TO GROUTING AND A"FINAL INSPECTION.. <br /> SIGNED _ TITLE: DATE.' Air- <br /> [2 (DRAW <br /> PL L N ON REVE�, SIDE <br /> FQR DEPARTMENT USE ONLY <br /> PHASE I ti ,xY` <br /> APPLICATION ACCEPTED BY - DATEA7 <br /> ADDITIONAL COMMENTS: <br /> PHASE. I GROUT INSPECTIO PHASE III F NAL I PECTION f <br /> INS-PECTION-BY DATE /� INSPECTION .BY ATE `� <br /> _. 9" 78 <br /> 'EW 14 26 Rev. 9%78 _ . � - � __ <br />