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t <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7S/ <br /> Telephone: (209) 4�,�-11 - 1. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued E�—"„ <br /> ( o ..p In Triplicates <br /> fi 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`ma'de ih, compliance with' San ' <br /> Joaquin County Ordinance No. 1862 and the Rules and" Regulations of the San Joaquin Local Health <br /> .District. F. .� <br /> y 4 <br /> EXACT STREET ADDRESS 41,E CITY/TOWN <br /> Owner's Name Phone <br /> Address ._ <br /> PC 3 <br /> City X., cl ze R/ <br /> Contractor's Name ll,4'` License# � � Phone` <br /> IS CERTIFICATE -OF WORKFIAN'S COMPENSATION INSURANCE ON FILE WITH,SJLHD? YES 0: � - <br /> TYPE OF WORK (Check) : NEW WELL[M DEEPEN ❑ RECONDITIONSo -QES..TRU.CTI.ONZ1- <br /> • - - .WEL-L--CHLORINATION�o"- "WELL i BAN�DONMENT i OTHER O <br /> r PUMP INSTALLATION L PUMP REPAIR CT' RUMP REPLACEMENT O .-_._. f <br /> DISTANCE TO NEAREST: SEPTIC ,TANKSEWER CINES apo ' PIT PRIVY --+ <br /> 3 SEWAGE DISPOSAL Z FIELD/ 0.'�-C . OL/SEEPAGE PIT OTHER <br /> PROPERTY LINEW PRIVATE DOMESTIC,- WELL_=L>:__ PUBLIC DOMESTIC_WE <br /> M ' INTENDED USS' TYPE OF.-WELL., i, � CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable To - Dia. Iof`Well Excavation 2 " <br /> L - fir.Domestic/private { _Drilled Dia`._o.fTWeJ]. Casingf� <br /> Domestic/public Driven Gauge of Casing . <br /> F "_Irrigation ; _ K Gravel Pack Depth-of Grout Sea <br /> Cathodic Protection <br /> otary Ty <br /> pe <br /> Disposal' ofn...fGro�ut <br /> eohysical r� formation <br /> Other ►�a ^4 .. <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION Contractor -R - 'c <br /> Type of Pump ..:. _....H. <br /> PUMP REPLACEMENT: C]State Work Done .�;. •"�" ""� ' <br /> PUMP REPAIR: ` ► , "` <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameterpprox "imate Depth ' <br /> A . <br /> ' ¢ Describe Material ana ce ure <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 Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> i"I certify that5in the performance of the work for which this permit 'is issued, I shall t <br /> not employ any ;person in such manner as to become s.ubject. to Workman's Compensation`s " <br /> laws of California."'' ' 3 <br /> il WILL CALL FOR A GROUT INSPE ION PRIOR TO GROUTING ANDA FINAL "INSPECTION. <br /> SIGNED Y. <br /> TITLE: , DATE: . Vin. <br /> i <br /> (DRAW PLT nTNON REVERSE SIDE <br /> ' <br /> FOR DEPARTMENT USE ONLY k . w <br /> PHASE I 5 <br /> PPLI AT10N ACCEPTED BY p DATE , <br /> ADDITIONAL COMMENTSI: Y <br /> .... <br /> PHASE..I Iv,.GROUT..-"DATEECTION <br /> ''PHASE ' II__.FIIVALINSPECT ON 7q...�. <br /> INSPECTION BY <br /> INSPECTION BY DATE 3 <br /> H 14 26 Rev. 9/78 : -._r _�. 9.78 . M <br />