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SAN JOAQUIN LOCAL ,HEALTH DISTRICTFOR permit No-7F-'5211 — <br /> FFICE USE �( 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> U" Telephone: (209) 4664781, Date Issued !a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 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 /> It 17 <br /> EXACT STREET ADDRESS G,�s»�� f �J �° _ CITY/TOWN �-��► <br /> a� Phoneme"2 2.9/ <br /> Owner's Name � - joau�^ ,O"X--742 <br /> Address f. - :� 1 v City <br /> Contractor' s Name /lc�r Li cense# Pk: 91-C6 Phone ILAC 3%/- /� 2 <br /> .01 <br /> IS CERTIFICATE OF WORKMAN'S C01APENSATION IN ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [] RECONDITION C3 DESTRUCTION 1. <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHERf.�I <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT Q <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 CONSTRUCTION SPECIFICATIONS <br /> r Industrial Cable Tool �- Dia. of Well Excavation <br /> � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public X Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea Fu// <br /> ► Cathodic Protection Rotary Type of Grout Cc-, C- <br /> Disposal Other Other Information <br /> Surface Seal Inst <br /> Geophysical al ed b <br /> Text a / <br /> PUMP INSTALLATION: p'Contr.actor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth ` o <br /> Describe Material and Procedure <br /> k I hereby certify that I' have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Homel�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!0" <br /> I WILL C FOR A GROUT INSPE TION PRIOR TO -GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 13��' C DATE: <br /> F DR W PLGT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I i� - ( 't , ATA E _if .7 <br /> APPLICATION ACCEPTED BY D �9 <br /> ADDITIONAL COMMENTS: IN <br /> PHASE iI GROUT INSPECTION Y PH AL INSPECTION <br /> INSPECTION BY IN DATE INSPECTION 8 DATE. -Z/-F`i <br /> I 1/78 2M <br /> i,FH 142Fi. . Rev- 12-77 . N- . __. <br />