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p SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.j7,-: 3 <br /> Telephone: (209) 466-6781 . <br /> 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT JDate Issued -a6- <br /> (Complete In Triplie�te). <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -, and/or :install the wor0 herein described. This application is made—in—,compliance with San <br /> O <br /> ryoaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 'I a <br /> 1 EXACTcSTREET ADDRESS CITY/TOWN a <br /> ' Owner's Name A �� I�. / - Phone,? �- 0 <br /> Address - J 3 3 a Ci tyf <br /> Contractor's Name 1° Licensef(, 1323 Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE--OF-WORK tChed—Q'. 4NEW-WEDITION DEST.RU.CTION(2 <br /> 14ELL CHLORINATION Q WELL ABANDONMENT ® OTHER-FJ <br /> 'PUMP INSTALLATION CI PUMP REPAIR 0 PUMP REPLACEMENTCER. - <br /> _ H: <br /> , DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES . - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES 0Z_k/SEEPAGE PIT OTTER <br /> hPROPERTY LINE - PRIVATE DOMESTIC WELL—.. PUBLIC DOMESTIC WELL <br /> } 4 'INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> �­ Inaustriai Cable Tool Dia. of Wel Excavation <br /> ` Domestic/private.' , Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> IrrigationGravel`'Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary w- j . Type of Grout 4' -i <br /> Disposal Other ' `• Other Information <br /> Geophysical ISurface Seal Inst, ed by: <br /> PUMP. INSTALLATION: �Con��rktor - - ' <br /> 1IType of Pump H.P. / t_ <br /> PUMP REPLACEMENT: astate Work Done .Q.�~ �,-�-� <br /> PUMP REPAIR: O State Work Done,,, x <br /> DESTRUCTION OF WELL_: Well Diameter .,APOrox;imate Depth <br /> Nscri be Material and Pr6cedure ' <br /> ., ,.. F it T• - <br /> . I hereby certify that I, have prepared this application and that the work will be done in accordanc+ <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 pers:6n in such manner as to become subject to Workman's Compensation <br /> laws of California:” <br /> I WILL CAL4AR GROUTPI ECTION PRJ10R TO GROUTING AN 'FINAL INSPECTION. <br /> SIGNED TITLE:. ' DATE: r- -Q � <br /> h!' LAERAWPLOT PLAN ON REVERSE SE - <br /> �� F R DEPARTMENT USE ONLY' <br /> PHASE I - <br /> PPPLICATION ACCEPTED BY;. DATE �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION \ PHASE III FINAL INSPECTION <br /> 7� <br /> INSPECTION BY t DATE INSPECTION BY ,~ DATE _L�� ' <br /> �EH 14 26 Rev. 9/78 111:! „.--g/.78` -.--_2M_� <br />