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SAN JOAQUIN LOCAL HEALTH DISTRICTEOR Permit No.-7 5 0� <br /> FFICE USE: 1601 E. Hazelton- Ave. , Stockton, CA 95205 <br /> Telephone: (209) '466-6781 Date Issued -/? 172 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex i,res 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 with <br /> San <br /> and/or install the work herein described': This application is made in compliance with San <br /> Joaquin County Ordinance ,No. 1.862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 34-.7.� /+F+ -0 We CITY/TOWN_ <br /> Phone 6 Z__ <br /> Owner's Name <br /> City ST <br /> Address '+ LAI <br /> Contractor' s Name /1 W� �� <br /> Li cense#3�7D�'�one <br /> IS CERTIFICATE OF IJOf'K lAPd'S CO"1PEidSA IO�l -11SURAINCE ONJILE'41ITFI�SJLii�3'? YE-S NO ' <br /> TYPE -OF.-WORK (Check) :- NEW WELL DEEPEN ❑ RECONDITION C3L - DESTRUCTHER ION❑' - <br /> WELL CHLORINATION 0,_,WELL <br /> PUMP INSTALLATION,❑ PUMP REPAIR❑ PUMP REPLACEMENT F-1 <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES__� PIT PRIVY Ii <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE RIVATE DOMESTIC WELL ."�`�— PUBLIC DOMESTIC WELL - =-- � <br /> r TYPE OF WELL CONSTRUCTION SPECIFICATIONS CAI <br /> INTENDED USE <br /> Industrial Cabl e Tool Dia. of Well Excavati on��'��/• 7'� i <br /> �Domesti•c/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack --. -w.----Depth- of -Grout <br /> I <br /> Cathodic Protection —Rotay `; YPe of Groutr 9 S <br /> Di spasal� f <br /> Other � . 'Other Information <br /> Geophysical !j <br /> Sur..face Seal Instal eOb ` <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump <br /> f PUMP REPLACEMENT: -]State Work Done <br /> PUMP REPAIR: .:Ostate Work Done- <br /> DESTRUCTION OF WELL: Wel l Diameter RrApproximate" Depth - <br /> Describe M_ater.ial and Procedure <br /> r <br /> this application and that the work will be done in accordant <br /> I hereby certify that I have prepared <br /> with San Joaquin County Ordinances , State haws , 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 INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> F` 11Z DATE: ='7 <br /> SIGNED TITLE: <br /> DR W PL T L N ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> H <br /> PHASE I <br /> D <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : -------------------- <br /> - <br /> PHASE II GROUT INSPECTION .h �PHASE. I-II--FINAL.-INSPECTION <br /> DAT <br /> INSPECTION BY DATE - . INSPECTION <br /> 2M. <br /> VU 1 AOC Dnv 19-77 " _ <br />