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g SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,7g_A/.V-1 <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')n compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations .of the San Joaquin Local Health <br /> District. (7 0*V ,0 -7-0,9 <br /> EXACT STREET ADDRESS VA 'ccgF� u CITY/TOWN <br /> Owner's Name �6 t,, �� I r �. _ Phone -` 941 <br /> Address [r.a� 1 ��,w,C �, �t C.00�O 2nd` City 4 ,.i <br /> Contractor' s Namec, ti License# 3 Phone 5- E <br /> IS CERTIFICATE OF WORKMAN'S COfiPENSATIO;! IEaSURAtlCE ON FILE WITH SJLHD? YES NO <br /> TYPE-'OF` WORK (Check}_-. -NEW `WELL;A DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATIONK, PUMP REPAIR❑ PUMP REPLACEMENT LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPO,5-A—LFIELD 90 r CESSPOOL/SEEPA9� PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL -ZLL 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 °P <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 �cc, U VqJ2 <br /> Type of Pump n k H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL.:-- Well _Diameter_ . - Approximate Depth <br /> Describe Material ana P� roce-Kure <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 k GROUT INSRECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ' <br /> 61 (DRAW PLOT L N ON REVER E SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 72 Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FJNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT l <br />:_EH 1426 Rev_ 12-77 1/78 2M <br />