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SAN JOAQUIN -LOCAL HEALTH DISTRICT <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 w�11111 <br /> ` This Permit Ex fres 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 <br /> k'oapuin Countyr Ordinance �� is made in compliance with San <br /> Y 1862 and the �Rules��and Regulations of .the.:San Joaquin -Local. Health <br /> a i s t r i c t. ` Qd i.c] 0, <br /> 2-7 . <br /> ' EXACT STREET ADDRESS <br /> esCI1Y%TOWN <br /> Owner' s Name '� d l Phone <br /> OJ <br /> Address <br /> C i tWl <br /> Contractor's Name ;License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATI01-11 IPJSURAINCE ON FILE WITH.5JLHD? YES NO <br /> ITYPE- OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONJK <br /> WELL CHLORINATION 0 WELL ABANDONMENT 155, OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP'-REPAIR❑ PUMP REPLACEMENT (] <br />' DISTANCE 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- ..-- T CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Domestic/private Cable Toon Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> K puic Driven <br />` Domestic/ bl -= --•- _ Gauge-.of CasingIrri <br /> Irrigation Gravel Pack 7epho_fGro_ut , <br /> Seal - ---� --_- -- - <br /> Cathodic Protection Rotary Type of Grout f <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP 'REPLACEMENT: <br /> []State Wark Dane <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter4Z_ <br /> C'Describ Mateand Pr ce ure Approximate Dep <br /> t' <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done inaccordance <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local ° <br /> i certify that in the performance of the .work for which this permit is issued, I shall r <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of Califo nia. " <br /> I WILL CALL F R GROU INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED)( <br /> TITLE: DATE: /(1 <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED6Y157- <br /> 4DDITIONAL COMMENTS: DATE 0� ... <br /> PHASE II GROUT IN ECTIONi <br />�NS�PECTION BY PHASE III UNAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE;$—•- . -- <br /> k{ <br /> 1426 Rpv. •Y7.9_77 _ r-: <br />