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OFFICE USE: 1601Hazelton Ave. , S,tockton,JCA y5 5 Permit No.7 _ r 7 <br /> Telephone: (209)466-6781 ftd <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> ` This Permit Expires 1 Year From. Date Issued <br /> Complete In Triplicate <br /> Dlication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> �i/or install the work herein described. This application is made in compliance with San <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ,strict. <br /> _ACT STREET ADDRESS ' / / o VD `� b� c� '� CITY/TOWN c64/e-I',,. <br /> ,wner's Name Phone <br /> cress d City K n <br /> ontractor's Name License# /y3-)vfPhone ,/Lz _ 77L <br /> e <br /> CERTIFICATE OF WORKMAN'S COMP S ION INSURANCE ON FILE WITH SJLHD? YES NO <br /> YPE OF WORK (Check) : NEW WELL Q DEEPEN Q RECONDITION Q DESTRUCTION Q <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIRCO PUMP REPLACEMENT Q <br /> STANCE 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 <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump -y—u E, H.P. 1.r- <br /> IwIP REPLACEMENT: [] State Work Done <br /> 'IMP REPAIR: (State Work Done 4/ h�� e <br /> .,STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .hereby certify that I have prepared this application and that the work will be done in accordant <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> filth 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 /> BILL CALL FOR A GROUT INSPECT N PRIG TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TLE: _ DATE: s OA 7 <br /> AW PLOT PL ON REVERSE SIDE <br /> r. FOR DEPARTMENT USE ONLY <br /> HASE I <br /> "DLICATION ACCEPTED BY okll ('cv OS DATE 0 a7 2e <br /> )ITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> "SPECTION BY DATE INSPECTION BY eY2 DATE <br /> 1-1426 Rev. 12-77 60 1/78 2M <br />