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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. 5 <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Date Issued41-11) - ' <br /> This' Permit 'Expires 1 Year From Date Issued, <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit t construc <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rul s and R ulatio s of. the San <br /> Joaquin Local Health <br /> District. <br /> EXACT. STREET ADDRESS--,) II 5evi <br /> CITY/TOWN <br /> Owner's Name 1•i R-r VA :UR A1Phone <br /> Address- . 03 5.o. ��k-r r a7 � City <br /> Contractor' s Name 4/ oF- License.#. —tPhone 4 <br /> IS CERTIFICATE OF WORKMAN'S COM"PENSATIOIN INSURANCE ON FILE WITH SJLHD? � YES NO <br />`-TYPE -OFR0R1C'"(-Check) :-' 15W_WELTCIS OEtPEN CI RECO9D_fT'1_W[�! 1rSTREiGTIOIV[ <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION-1� , 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 V1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of Well Excavation -d� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout . <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Al's <br /> Type of Pump CI — <br /> PUMP REPLACEMENT: El State Work Done ala <br /> PUMP REPAIR: Q State Work Done <br /> 1. oG G�ELL G+��p, a A <br /> DESTRUCTION"11-WEII.: Well Diameter pproxima e Depth "t <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> I 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: 1 DATE: Xf <br /> (DRAW PLOT PLAN ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE a o �� <br /> Gu I nor, Do 11_77.. ' `` 1/78 ; 2-M_ <br />