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SAN JOAQUIN LOCAL HEALTH DISTRICT fzv L- <br /> 'FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 Q- <br /> ___-_ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex i res 1 Year From Date Issued Y-8 fdr, <br /> Complete In Triplicate 7-1 Z Cdb_d.,LNc <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 /> ,'oanuin County Ordinance r,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSF-�w lao CITY/TOWN fAeCA <br /> Owner' s Name m - �n + VO Phone e,5 ,'- d- C11g <br /> Address t� 141 / ,;w City YY ni rdc•c 6 .. <br /> Contractor's Name License# Phone 56 <br /> IS <br /> 6IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE 1rJITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [] DESTRUCTION[ <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Q 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rnera � 1c" H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: lS= 7Z <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r DATE 3-11--2-1 <br /> ADDITIONAL COMMENTS: <br /> P AAI GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE )7--9" <br /> iT <br /> 4�17 8 2M <br /> EH 1426_ - ReRev. --12-77- - <br /> " <br />