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SAN JU,AQUIN 10CAL HEALTH UIS MIC l <br /> FFICE USE: 1601 E. FlazeltonAve. , Stockton, CA 95205 Permit No.Zg�63i <br /> Telephone: ,. (209) .466-.6.781 i <br /> APPLICAT.ION .FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> 0(J <br /> This Permit Expires 1 Year From mate 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 theiwork herein desc.r,,ibed. , This application is made incompliance with San <br /> 'can-in County Ordinance -No. 1862 and the ul es ,.and Regul ati oris of -the S n Joaqui n.:Local; Health <br /> District- �O.3srni 5e� vF /3a���,;/2� <br /> EXACT STREET. AD S.` �T '��' CITY/TOWN 1 <br /> Owner's Name • Phone ' <br /> Address r � ... `T^ . . 7 City <br /> Contractor's Name l — rw:;,�5' Li nse#)I'�2'3`33ho'ne;49?'Vig <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATiO'N INSURANCE ON FILE WITH SJLHD? YES '�r 140 <br />-TYPE dF WORK(Check}:-- NEW WELL ITY DEEPEN ❑�` RECONDITIQN ® DESTRUCT <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION FO' PUMP REPAIR E) PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK- EWER 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 CONSTRUCTION SPECIFLCATIIONS <br /> Industrial Cable Tool Dia. of Well Excavation . TGA <br /> i/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 73 f <br /> Irrigation Gravel Pack Depth of Grout �v = cv <br /> Cathodic Protection ✓Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ urface Seal Installed b <br /> PUMP INSTALLATION: Contractor` <br /> v Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: DState Work Done <br />. DES-TRUCTIO.N.OF_WELL: _ Well _Diameter Ap.p.roxi.mate-,De.pth <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: /--� iZEE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR. DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE UIJINAL INSPECTION <br /> INSPECTION BY' DATE_J-_Z_8--7, INSPECTION BY DATE <br />;EH 1426 Rev. 12-77 7�/y�� dl W 1/78 .- 2M <br />