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- illi <br /> V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE• 1601 E. Hazelton Av&,'' Stockton, CA 95205 Permit No. g <br /> Telephone (209)"A66-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <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'J'herein described. This application is made i'n compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules- and Regulations of the San Joaquin Local Health <br /> District. <br /> ' EXACT STREET ADDRESS Gm e o ViJ CITY/TOWN <br /> Owner's Name Ocs�v� '� �` �.. r� _ d Phone ?.3i- Y503 <br /> Address 11/0 w City <br /> r License# 6 Phone <br /> Contractors Name. �� r ✓' j3 -� — ------ T <br /> IS CERTIFICATE OF. WORKMAN'S COMPENSATIO,I INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M- DEEPEN ❑ RECONDITION [3 DESTRUCTIONC3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER( � <br /> PUMP. INSTALLATION M PUMP REPAIR 0 PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK v O SEWER LINESra o 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 A <br /> Domestic/public Driven Gauge of Casing 0 <br /> t Irrigation Gravel Pack Depth of Grout Sea 40& s` <br /> Cathodic Protection __A Rotary Type of Grout 0.6 <.. <br /> f Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> [ PUMP INSTALLATION: 'Contractor ��� H. V . <br /> P. <br /> ! Type of Pump - a <br /> ` PUMP' REPLACEMENT: wCJ._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 accordant <br /> with San Joaquin­-C6Unty .Ordinances.,. _State Laws.,--and-Rules and Regul.at,ions 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 Californian." <br /> I WILL CAL FOR A GROQT INSPECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED L.�, TITLE: c�. DATE: 'J -C'!- <br /> I� <br /> (DRAW PLUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ADPL I CATION ACCEPTED BY DATE I '7k <br /> ADDITIONAL COMMENTS: <br /> PHASE II ,GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BJMXA, DATE r1-1�1 1� INSPECTION BY DATE <br /> FH 1426 Rav_ 12-77. '� 1/78 21A <br />