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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. <br /> Telephone: .(209) 466,-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 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 R les and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 1a/hr- 1. 10 &?12—eaf Aw? r " yz-./M„4M�C CITY/TOWN_ <br /> Owner' s Name &A 2 c L1,,, , �Rc�s, _ Phone ALL Z-- ZZ? <br /> Address W Az-g!'/uty Citya•- <br /> Contractor's Name 11A,11 Ilef? (_ _ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIC RA^ICE M FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 29'" PUMP REPLACEMENT ❑ s. <br /> DISTANCE TO NEAREST: SEPTIC TANK/ria,-( SEWER LINESNd—t PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE36. 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_ S u h m-e �—e H.P. <br /> PUMP REPLACEMENT: Ra-State Work Done&Rz9,--44 L ,�Z!�TCi7 &v, Zz /fir®nom/! <br /> PUMP REPAIR: ❑State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana 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 JNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2 <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> PHASE I FO DEP RTMENT USE ONLY <br />, <br /> APPLICATION ACCEPTED BYDATE_ &J Wa��k= Z <br /> /•Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATV-s. <br />`_..__142.6 . Rev_.__12-77__ .—_�_ _. <br /> 1/78 2M_ , <br />