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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave. , 'Stockton, CA 95205 Permit No.;77- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,&-O.. . <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 -Rules and Regulations of the San Joaquin Local. Health <br /> i District., <br /> I EXACT STREET ADDRESS �� /: eA S7- SAIZAP =E__ .. CITY/TOWN S'AQC, 7-aY <br /> -Owner's Name ✓� P,'. �' 'JI N � ' ,: ?ts'£44 __. Phone q3�- Z� <br /> Address �5� /1 S 7' �l��Pf' ,E- _ _ City SZ-04-A 0W .. <br /> Contractor's Name C� �I - �&v! . 0 J VL�License# Phone Y6Z- 6:s".97 = <br /> ' <br /> IS CERTIFICATE OF WORKMAN'S COFMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION M DESTRUCTION M <br /> WELL CHLORINATION C7 WELL ABANDONMENT a OTHER ( <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT 0 <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 16 <br /> -Domestic/private Drilled Dia. of Well Casing ,_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout 'Seal 6-6 <br /> Cathodic .Protection �i�_.__.Rotary., Type of .Grout - 0 / E <br /> Disposal Other Other Information <br /> Geophysical = Surface Seal Instal ed;by: <br /> _ t <br /> PUMP INSTALLATION:-, Contractor � �Z'��I�jG r� � �- <br /> Type 'of 'Pump �r. Lli H.P. % - -- <br /> f PUMP; REPLACEMENT: ❑State Work Done F ' <br /> ts. <br /> PUMP REPAIR: ❑State Work Done A ; � s <br /> ' DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe'Material and Procedure . � <br /> I hereby certify 'that ,I have prepared this application and t-ha.t- the work will be done. in accordance <br /> with. San Joaquin ,Cdtinty, Ordinances , State Laws ; and Rules and' Regulations of the San Joaquin Local <br /> Health District. ` Home'-'owner or. li.censed agent' s signature, certifies the following: <br /> "I certify that in the performance;oflthe work for which this permit is issued, I shall � <br /> , <br /> not emply any person in such manner as to become"- subject to W0rkma-nY' -;'Compensation t <br /> laws of alifor p, <br /> I WILL CALL ORA RO IN5 CTION RIPR TO GROUTING 'AND INAL INSPECTION. <br /> SIGNED WA4, TITLE ' DATE: <br /> fIUAWI PILOT PLAN ON REV-ERSE SIDE <br /> FOR DEPARTMENT US-E ONLY <br /> t PHASE I � n �- <br /> APPLICATION ACCEPTED BY C #-DATE � �4� <br /> ADDITIONAL-COMMENTS - <br /> PHASE II GROUT INSPECTION PHASE III "_INAL I.NSPECTIION <br /> SPECTION BY DATE =a -1 INSPECTION B,Y .- } `j:. DATE <br /> Ni a9r, Pati, 19-77 /78 2M <br />