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SAN JOAQUIN LOCAL. HEALTH DIS <br /> fRICl <br /> FFICE USE: 16. 1 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> ff- 1651 <br /> Tel <br /> (209) 466-6781 <br />-- r � APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued���¢' <br /> This Permit Expires 1 Year From Date Issued. lLik L -76, <br /> Complete In Triplicate 3 Y7-1 �.ST/IV' <br /> I�g 3 z. s u ~�.� �—o3U-�� <br /> Application is hereby made to the San Joaquin Local H lth District for a permit ;Olt <br /> cons q uc t <br /> and/or install the work herein described. This appl 'ca ion is made in Complia��ace h nJoaquin County Ordinance No. 1862 and the Rules and eM ations o.- � Sa ' Jo?qu1 ��'0 1 th <br /> District. /r¢ <br /> m� / R T L.V _ / So d F/ <br /> EXACT STREET ADDRESS CITY/TOWN M TGA <br /> Owner' s Name Phone_ V1 <br /> Address / 3 4.e,?-I- s City TGf'r <br /> Contractor's Name „/ License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IINSURA"!CE ON FILE WITH SJLHD? YES 110 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATIONa PUMP REPAIR❑ PUMP REPLACEMENT ❑ ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <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 /> PUMP INSTALLATION: Contractor 61 "i1,5i ?If <br /> Type of Pump H.P. 3� - <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 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 CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND A FINAL INSPECTION <br /> SIGNED TITLE' o)%0 We TE: C7-�� <br /> DRAW PLOT PL N ON R ERS ., SIDf <br /> FOR DEPARTMEN E O Y ` <br /> PHASE 1 —79 <br /> —79 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE NSPECTION BY DATE <br /> ,EH 1426 Rev. 1.2--77 1/78 2M <br />