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SAN JOAQUIN LOCAL HEALTH DISTRICT x <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.`7'�_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued —9-7 <br /> _ . (complete In ;Triplicate) I` <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 the Rules and' Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS A';,�V ./ CITY/TOWN <br /> Owner's Name die lt5 l o7 Y/ Phone l� <br /> Address �. •City .T � �� <br /> Contractor's Name 7-0 Zl" License <br /> -373 Phone <br /> IS CERTIFICATE OF WORKMAN'S COliPENSATION INSURANCE ON FILE WITH SJLHD? YES `may 0 � <br /> TYPE OF WORK (Check) : NEW WELL uY�DEEPEN ❑' RECONDITION 0 DESTRUCTION[J � . <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 � N <br /> PUMP INSTALLATION Q PUMP REPAIR 0, PUMP REPLACEMENT,. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DZMESTIC WELL <br /> } -r INTENDED USE TYPE OF-WELL.- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic,/private _ F.� Drilled -Di-a. of Well Casing r4 r�4 <br /> —Domes tic/PUbl'ic Driven � Gauge of-.Casing 4 <br /> Irrigation Gravel Pack ` Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> f Geophysical Surface Seal Installed it <br /> PUMP INSTALLATION: Contractor <br /> € Type of Pump H F <br /> .PUMP REPLACEMENT: Mate Work Done v -- --r <br /> PUMP REPAIR: _ <br /> QState Work Done <br /> !DESTRUCTION OF WELL: dell Diameter Approximate Depth <br /> Describe Mate'rial and Procedure `I <br /> 1--hereby certify that I have prepared this application and that the work will be done in accords( <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 m <br />+ . not employ -any person in such manner as to become subject to Workman's Compensation x <br /> laws of California. " <br />� I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> s SIGNED TITLE: DATE: TS `) ,9` <br /> DR WP T PL ON REVERSE SIDE I <br /> PlASE I F R D PARTM T USE ONLY <br /> APPLICATION ACCEPTED BYDATE 7 7 <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION , E <br /> INSPECTION BY DATE INSPECTION BY DATE ����'7f <br /> EH 14 '26 Rev. 9/78 9/ 2Mj[ <br />