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. JJ SAN JOAQUIN LOCAL `HtALTH DISTRICT r <br /> FFICE USE: y16O1E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 y 7/ <br /> Telephone: (209) ,466-6781 { <br /> Date Issued <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 fora permit to construct F <br /> and/or install the work herein described. This application is made in compliance with San <br />,'oanuin County Ordinance No. 1862 and the Rules and Regulations of theiSan Joaquin Local Health <br /> District <br /> f <br /> O4 4 i 077 S'-(-'VO-z- <br /> . • � = !�ACITY/TOWN <br /> EXACT STREET ADDRESS v <br /> Owner' s Name,s� <br /> AP � <br /> l/ , � Rr�c Phone <br /> � . Ci ty. <br /> Address <br /> Contractor' s Name License# Phoner�= 3;9q <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN I�ISURA�dCE ON FILE WITH SJLHD? YES v NO <br /> 'rp <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN El ENT <br /> ❑ DESTRUCTION ED - <br /> WELL CHLORINATION C3 WELL PUMP RBEPADONM <br /> IR❑ NT SMP REPLAOTHERCE ENT [9— <br /> PUMP INSTALLATIONEl <br /> 4• <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 <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel rack Depth of-Grout-Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Instal ed by: <br /> JPUMP INSTALLATION: Contractor <br /> p• <br /> Type of Pump- , ;,{ t H. <br /> PUMP REPLACEMENT: ❑State Work. Done <br /> PUMP REPAIR: ❑State Work,:: Done <br /> : DESTRUCTION 4F WELL: Well <br /> Diameter Approximate Depth <br /> Describe Materia I and Procedure <br /> 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. 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 /> II WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTIONill . <br /> DATE: <br /> SIGNED TITLE: d <br /> ��RW PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 9 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 1INSPECTION BY DATE INSPECTION DATED <br /> i <br /> 1/78 2M <br />