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SAN JOAQUIN LOCAL HEALTH 015iKICI ' <br /> r�.FOR FFICE USE: 1601 E. Raze�ton Ave. , Stockton, CA 95205 Permit No. �R/(� 3 7 <br />' Teleph e: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit` Ex fres 1 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 /> Joaquin County Ordinance No. 1862 and .the Rules and Regulations of the San Joaquin ;Local Health <br /> District. <br /> EXACT STREET ADDRESS C7. fru <br /> CITY/TOWN orr i <br /> Owner's Name Trza ZrUJM, Phone „ t <br /> Address �.�i City i <br /> Contractor's Name Li cense Phone <br /> TS `CERTIFICATE OF WORKMAN'S'COMPENSATIO'N INSURAINCE ON FILE WITH SJLHD? ' YES Y_ NO <br /> TYPE OF WORK (Check) : NEW WELL0 DEEPEN ❑ RECONDITION ❑ " DESTRUCTION( <br /> WELL CHLORINATION ❑ WELL ABANDONMENT M OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o , <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 /> Industrial Cable Tool ' Dia. of Well Excavation Z,2 <br /> Domestic/private K_ ., Drilled Dia.- of Well Casing r' <br /> Domestic/public Driven =. `. Gauge of Casing Red <br /> Irrigation _Gravel Pack— -. .._.Depth-.of_.Grou.t Sea _ <br /> Cathodic Protection Rotary Type of Grout �'F'&aAr <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: ❑State Work Done_ . <br /> DESTRUCTION -OF WELL: - , Well Diameter , - ��-A- proximate`Depth <br /> Describe Mate ial andrRrocedure <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- agen.t:'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 GRO T - SPE N PRIOR TO GROUTING AND A FINAL INSPECTION. o <br /> SIGNED TITLE: � DATE: ' <br /> (DRAW PLUT PLAN ON REVERSE,-SIDE <br /> --- FOR DEPARTMENT USE ONLY <br /> PHASE T DATE S/77ff <br /> APPLICATION- ACCEPT'ED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROQ T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYWKAAnk±iLfDATEo�—�,—" INSPECTION BY DATE f <br /> FN l def Rav -19-77 LL;� . . 1778 2M ii� <br />