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SAN JOAQUIN. LOCAL: HEALTH DISTRICT <br /> FOR5;!-QFF!lCE USE: ri 1,601 E. Hazel ton Ave. , Stockton, CA .95205 _, .. Permit No. 7 9-x/59 <br /> TelepRiomet�*-(209) 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issaed +5-/d-2 <br /> This Permit .EX ires 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 /> ,'oaquin County .0rdinance No. 1862 and: the Rules and Regulations of the San Joaquin Local Health <br /> District. <br />' EXACT STREET ADDRESS 3 4�,/ CITY/TOWN <br /> Owner's Name ef Phone g 3- 0- <br /> Address . 17" city� <br /> Contractor' s Name, �,�,zg_ ,,'A,�,��I1� �v License# p Phone.`" <br /> IS CERTIFICATE OF WORKMAN'S CO11,IPENSATIO'N IIISURAINCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ -RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT d _ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [J ' <br />'f <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 <br /> Domestic/private Drilled Dia. of Well Casing__46 s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection Zotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> i • : Type 'of Pump H.P <br /> PUMP REPLACEMENT: ❑State Work Done <br />; PUMP REPAIR:-- ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - -- -- Approximate Depth <br /> Describe Material and Procedure <br /> I f <br /> I hereby certify that-I have .prepared this application and that the work will be done in accordance <br /> with San Joaqui0 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' I WILL CALL FOR AiGROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ESIGNED �� TITLE: DATE: <br /> I <br /> (DRAW PLOT PLFN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION .ACCEPTED; BY DATE -,2q <br />;ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />[INSPECTION BY DATE INSPECTION BY DATE <br /> SEH 1426- Rev'. 12-77 f V" � -._" - - -- =- CP I/7b2M' <br />