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5AN JOACUIN LOCAL" HEALTH DISTRICT <br /> y <br /> EQR <br /> FFICEP�_O � USE: 1601 E. Hazelton Ave.", Stockton, CA 95205 Permit No. 7�_i�/3 <br /> Telephone "("209) 466-6.781 "" �" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued f,;z- 7 <br /> F This Permit Ex ire$ I 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 /> : 'oaquin County Ordinance No. 1862 and the, Rules and Regulations of the San Joaquin Local Health <br /> DiStrict. <br /> EXACT STREET ADDRESS v f _ CITY/TOWN;:� <br /> Rg.�� <br /> Owner's Name Phone gg 7 — 3 2-S-7 <br /> Address City _�.� � r�r. <br /> Contractor's Name Lv '.) �'cf;-,,. c LicenselV/1?0 Phone 75`'-3 `/ `/ )/ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES Ido z� <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION El VELL ABANDONMENT ❑ OTHER ❑ <br /> j PUMP INSTALLATION MP REPAIR❑ PUMP REPLACEMENT <br /> , DISTA�fCE 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 /> I ustrial. Cable Tool Dia. of Well Excavation <br /> t omestic/private Drilled Dia. of Well Casing <br /> 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 /> k Geophysical Surfa Seal Installed b ;r <br /> PUMP INSTALLATION: Contractor .� v�'G <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedurea .. <br /> i <br /> EI 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 ig issued, I shall <br /> t not employ any person in such manner as to become subject to Workman's . Compensatioh <br /> laws of California." <br /> I WILL CALL/FOR A GROUT INSPECTIO P FIOR TGROUTING AND INAL INSPECTION. <br /> .SIGNED '' TITLE _ DATE: <br /> (DRAW PLOT PLVN ON REVERSE SID <br /> FOR PARTMENT USE ONLY <br /> PHASE I ,., r � <br /> APPLICATION ACCEPTED BY T DATE, 7 7e <br /> ADDITIONAL COMMENTS-:----- ; <br /> PHASE II GROUT INSPECTION PHASE LJ I F_IX4 INSPECTION <br /> INSPECTION BY DATE '' "INSPECTION BY DATE_ 3-0:V <br /> :EH}1426 Rev.- 12-77 1 /78 2M <br />