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�.._ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 71- 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-649_ <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 incompliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of-the San Joaquin `Local Health <br /> District. <br /> EXACT STREET ADDRESS 5�1 4•D ACA mo 12 © Rt �'c CITY/TOWN <br /> Owner's Name kd 0 b fl ovT,4At Phone `e'3/— 0561 <br /> Address r0, �[ A d A ateet D City :f� <br /> Contractor's Name 1/du I a /I C fL 1 6,da Li cense# M/ Phone 56�_ y <br /> T _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES ---- N0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [] DESTRUCTION[] �l <br /> WELL CHLORINATION 0 WELL ABANDONMENT © OTHERE:3 <br /> PUMP INSTALLATION 2-- PUMP REPAIR❑. RUMP REPLACEMENT Q a <br /> DISTANCE TO NEAREST: SEPTIC TANK SC°-J SEWER LINES 52)' PIT PRIVY <br /> SEWAGE DISPOS L IELDs"of � CESSP L/SEEPAGE PTT- OTHER <br /> PROPERTY LIN%d`-tPRIVATE D ESTIC WELL PUBLTG-DWESTIC WELL :: <br /> INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial— Cable Tool Dia. of We -1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ss�h t� -i 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__pre.par�d-� LW�` <br /> �I�p�}-'i-catfion _and _that_ tFie work wi 11 be 11 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 /> r 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 C&ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: �JDATE: <br /> -r <br /> PL N ON REVERSE SIDE) � - <br /> R <br /> DUARTMENT USE ONLY <br /> PHASE I <br /> AQPI�CATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: 7K9 <br /> PHASE II GROUT INSPECTION PHASE III 'FIN4LOLNSPECTION q <br /> INSPECTION BY- � DATE INSPECTION BY ATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />