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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> lv t 7-df% <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 10:23 -7 <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In. <br /> Trip i ee <br /> ta Application is hereby made to the San Joaquin uin Local Hea th District Permit to construct'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 (1/ CITY/TOWN <br /> c�t , <br /> Owner's Name 'a d v r/z. ' Phone 6--7 <br /> Address / 8 fc c . 'MA Ci ty I 7�2� hTz:,, <br /> Contractor's Name License# U5�76� Phone�6 Z <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 FILE WITH SJLHD? YES L--- NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Imo'' PUMP REPAIR 0 PUMP REPLACEMENT 11 <br /> DISTANCE TO NEAREST: SEPTIC TAN '- - SEWER LINESPIT PRIVY <br /> SEWAGE DISP SAL FIELD,,,"' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEi44PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> z-__-Domestic/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 /> Geophysical Surface Seal Installed by <br /> PUMP INSTALLATION: Contractor •-�-- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth' <br /> Describe Material and Procedure <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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ,2 7 <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: p <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �}� DATE 6 a 7 <br /> EH 1426 Rev. 12-77 1/78 2M <br />