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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. `7a- 69 <br /> Telephone: (209) 466-6781 <br /> 1APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 6 <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 /> District. <br /> 91 <br /> EXACT STREET ADDRESS CITY/TOWN i <br /> Owner's Name PhoneL/ � <br /> Address ry V.E� - City <br /> Contractor's Name -� � � License# rl--??3 Phone T DLJ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR_A1,4CE ON FII.E'WITWS.JLHD? YES✓ No J, <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN ❑ RECONDITION [] DESTRUCTION F1 <br /> WELL CHLORINATION Q `-WELL ABANDON IN Q OTHER❑ <br /> PUMP. I-NSTALLATION C1PUMP REPAIR PUMP REPLACEMENT Ea - � . <br /> DISTANCE TO NEAREST:­ SEPTIC-TANKS �_SEWER-LIpNES �PIT PRIVY <br /> � <br /> ► SEWAGEDISPOSAL FIELD ' CESSPOOL`/SEE!�Qf- PIT' OTHER C/1 <br /> PROPERTY LINEi - PRIVATE DOMESTIC WELL!— ­PUBLIC DbMESTIC WE� l.0 <br /> INTENDED USE TYPEiOF-WELL... CONSTRUCTION SPECIFICAN ONS k <br /> IndustrialH Cable Tool Dia. of Woll' EXcavation _ <br /> omestic/private Drilled Dia.' of Well ..Casing ' <br /> ..Domestic/public, <br /> `� Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth of Grout Sea _ <br /> Cathodic Protection 3ARotary Type of Grout FVdI <br /> Disposal -Other ' Other Information <br /> Geophysical `` ' 'V ' Surface Seal Insta ed by-7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - - t ,. . ; H.P. <br /> PUMP .REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: � - - . #Orate Work Done �_-_ <br /> DESTRUCTION 'OF WELL: Well Diameter ""` ' Approximate Depth <br /> Describe Material and Procedure i <br /> Ihereby 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 /> t laws of California:" <br />. I WILL CALL FOR A GROUT -INSPECTION PRIOR TO GROUTING AND A FINAL IISPECTION. <br /> SIGNED. , L71 All-, TITLE: DATE: 79'" <br /> ` <br /> _(DRAW PLOT PL' N 'ON REVERSE SIDE)FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION—AGCEPTED BY DATE <br /> ADDITIONAC COMMENTS: <br /> PHAS i GROUT INSPECTION PHASE II . FINAL.-IN.SPECTION <br /> INSPECTION DATE 7 'INSPECTION BY - . DATE -,�":7 <br /> SEH 14 26' Rev. 9/78 9%78 - 2M� <br />