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`--- SAN JOAI)U I N 'LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,-Stockton, CA 95205 Permit No. -7 q s <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> (t:omplete_In Triplicate) <br /> Application is hereby m ade .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 N6 1.862 and the Rules and" Regulations of the San Joaquin Local Health <br /> District. t <br /> EXACT STREET ADDRESS �wJC` y%OWN <br /> Owner's Name -_ - <br /> Phone <br /> Address a <br /> " <br /> - - C i ty �; <br /> Contractor's Name License#A 13 7-3 Phone 3C. 3 <br /> -IS CERTIFIGATE�OF W )RKttAN'-S-GOMPENSATION�I-NSURA"ICE=ON `FILTE�WITH-SJLHQ? <br /> 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN <br /> CI RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER fR <br /> PUMP INSTALLATION Q PUMP REPAIR 0— PUMP REPLACEMENT <br /> y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> IELD <br /> SEWAGE DISPOSAL CESSPOOL/SEEPAGE PIT OTHER 1 <br /> y <br /> PRO.P_ERTY LINE=TPRIVATE DOMESTIC WELL— PUBLIC .DOMESTIC WE <br /> INTENDED USE , <br /> TYPE OF._WELL...- CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,- _omestic/private rilled_'. <br /> Domestic/pub14c t_:.2 -- Dia. of Well Casing <br /> Irrigation ` riven Gauge of Casing r <br /> Gravel Pack Depth of Grout Sea <br />��Cathodic Protection t Rotary - Type of Grout <br /> Disposal Other Other Information .1 <br /> Geophysical _ Surface Seal Insta ed <br /> PUMP INSTALLATION: <br /> Contractor V ! <br /> Typetof" Pump �, t <br /> PUMP REPLACEMENT: "`" <br /> H.P. i <br /> [-State Work Done; <br /> PUMP REPAIR.: <br /> - ]S:tate..-Wor_k_Done--�.� <br /> DESTRUCTION OF WELL: Well Diameter <br /> gscri e Mter�.a andf 'Proce ure Approximate Depth <br /> I hereby certify. that I have Rrepard thi.s�applicatio nd th�tte work will be done in <br /> accordandi <br /> with San Joaquin County Ordinances," State L`aw_s;-' 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 fol^ which this permit is issued, I shall ° <br /> not employ any person in suc} manner as to become subject to Workman 's Compensation ! <br /> laws of California. " <br /> I WILL CAL OR GROUT IN CTION PRI TO GROUTING AND A FINAL" <br /> SIGNED INSPECTION. ; <br /> TITLE: r <br /> i~ R W P T L N ON REVERSE IDE _< �- DATE:-- <br /> PHASE I R DEA RTME T, USE , LY <br /> PPP-LICATION'�ACCEPTED BY <br /> ADDITIONAL COMMENTS: � M �� DATE Lf O- 77 E <br /> PHASE IT GROUT INSPECTION PHASE III 'FI <br /> DATE NAL INSPECTION 1 <br /> 1SPECTION BY <br /> �� <br />:H 14 26 Rev. 9/787 ` INSPECTION BY DATE <br />