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SAN J,OAQUIN LOCAL .HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> I Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit. Ex ires 1 Year From Date Issued <br /> fl,bp <br /> Complete In Triplicate � o. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. This application -is made in compliance with San ; <br /> Joaquin County Ordinance No. 862 and the Rules and Regulations of the .San�oaquin Local Health <br /> District. /,e�� co 1--y-q �. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name V VC a1I Phone S. <br /> Address City <br /> Contractor's Name /� 1 License# Phone �' -� <br /> IS CERTIFTCATE.OF WORKIIAN'S COMPENSATIOt! INSURANCE ON FILE WITH SJLHD? YES Nn.// <br /> TYPE'OF WORK_ (Check) : N W1,WE.LL-0 DEEPEN ❑ RECONDITION DESTRUCTION <br /> \K A, p y WELL CHLORINATION;[) WELL ABANDONMENT 0 . OTHER ❑ <br /> PUMP IN-STALLATION 04 PUMP REPAIR❑ PUMP REPLACEMENT gid" <br /> DISTA•NCETTO -NEAREST:- SEPTIC (TANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/ OTHER <br /> PROPERTY LINE -.PRIVATE DOMESTIC WELL PUBL C DOMESTIC WELL ' <br /> INTENDED USE TYPE OF DELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable--Tool Dia. of Well` Excavation { } <br /> Domestic/private Drilled Dia. of Well Casing p <br /> Domestic/public t Driven Gauge ,of Casing <br /> —Irrigation A Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Others ,.,Other Information <br /> Geophysical Surface Seal Installed b <br /> ;� 1r <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump ��r'h�°.,� i C- H.P. 5-- <br /> t <br /> PUMP REPLACEMENT: []State Work Done., <br /> PUMP REPAIR: ❑State Work Done <br />- DESTRUCTION OF WELL: Well Diamete ,. Approximate Depth <br /> r' <br /> Describe MaterIal and Proce ure <br /> I hereby certify that I havd-rprepared this application and that the work will , a -d ne in accordance' <br /> with San Joaquin County Ordinances , StaterLaws , and Rules and Regulations of- the San Joaquin Local <br /> Health--d strict. Home owner-or.-licensed agent' s signature certifies the following: <br /> 'I certify tfiat-in,the performance�,of the work for which this permit is .issued, I shall <br /> not employ any pe,rson4Jn suchmanner as to become subject to Workman' s Compensation <br /> laws of California. , <br /> I WILL CALL FOR A--GROUT INSPECT_ION :PRIO_R TO GROUTING AND A FINAL INSPECTION. �/ <br /> SIGNED TITLE: DATE: v7 <br /> DRAW PLT PLN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED (BY DATE <br /> ADDITIONAL. COMMENTS: I -'­ . _� { <br /> - PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br />; INSPECTIONBY : DATE. INSPECTION BY DATE s I--7g <br /> 4' » <br /> p <br /> Cu ,Aor oe,. ,7_77 /� d3`�' 1./78 2TI <br />