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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.9,7- 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g-�?-?9 <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS a ` 1 /Q, /m CITY/TOWN_ <br /> Owner's Name Soo ca/a r Phone <br /> ,Address Q city <br /> Contractor's Nam License#/,t ?7 !""Phone "i- — 74 76 <br /> IS CERTIFICATE OF WORKMAN'S1 NSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN Q RECONDITION Q DESTRUCTION[ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � y' <br /> PUMP INSTALLATION Q PUMP REPAIR59 PUMP REPLACEMENT ( <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPD7bL/SEEPAGE PIS- OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL A' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> rrigation 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 L <br /> Type of Pump H.P. 3a <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: [State Work Done �i - ,-�® /j-p ot,6 3a /W y- kA lef� t� <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 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 person in such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTI P 0 , ROU ING AND A FINAL INSPECTION. <br /> SIGNED DATE: <br /> f FDJ4�PL L VERSE SIDE) <br /> tl R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION pHA E II FINAL INSPECTION <br /> INSPECTION BY Ua DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 - .. 9 78 2 <br />