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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF�CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 / --3/3 <br /> Telephone: (209) 466-6781 G� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 /> Joaquin County Ordinance No. 1862 and th Rules and Re lations of the S$an Joaquin Local Health <br /> District. �L PWCJ /�u"-fp m .t/"c-c/IV&/(/ <br /> EXACT STREET ADDRESS I� �,4A1 Arl,& 4W. Apf44A �.IV& / L.r/r/1' 4tiTY/TOWWN <br /> Owner's Nim 017V 84/� � .00 Phone a 3S �Sj <br /> Address �I G Q oe City !` Frrx�c.si <br /> Contractor's Name License# 011T741Phone HEy y,>r-3P <br /> I5 CERTIFICATE OF WORKMAN'S CO!"PENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION Q— WELL ABANDONMENT O OTHER Q <br /> PUMP INSTALLATION CT PUMP REPAIR❑ PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK A-*'u" !SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOSA FIELD CES—SP 5L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ^Domestic/private Drilled Dia. of Well Casing <br /> �llomestic/public Driven Gauge of Casing <br /> --- Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed : <br /> PUMP INSTALLATION: Contractor �iv`r'r+ f�j 1'�`�"�.� 7`' `��,ti'X : l <br /> Type of Pump_ H.P. <br /> PUMP REPLACEMENT: [7 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <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 /> laws of California. " <br /> I WILL CAjLL FOR A Al GRP INSPECTIO PRIOR TO GROUTING AND FINAL INSPECTION. / <br /> SIGNED a y '°` '°� TITLE: 1 DATE: <br /> —FD-RA—W-FLU--PLAN ON REVERSE SIDE) <br /> PHASE I <br /> R E ENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY / (� �- C__ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION 8Y DATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />