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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 (off <br /> Telephone: (209.) 466-6781 <br /> APPLICATION FOR "WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This. Permit Expires 1 Year .From Date I.s'sued <br /> Complete "In. Triplicate MA1 L PUEM 17- 7o aGUN <br />%pplicati'on is hereby made to the San -Joaquin "Local Health- District for a permit to construct <br /> ind/or install the work herein described. This application is made- in compliance with San I <br />'oaqui n County Ordinance No. 1862 a d the Rules .and Regulations.,of the San Joaquin Local Health � <br />)istrscl- y <br /> EXACT STREET. ADDRESS to/V �/� 7�4 -lo! 6� CITY/TOWN /�-r <br />)weer s' Name �� ��� Phone 3�� <br /> 1/�� 4- <br /> address [-7 ` 7 C' 1-3 S 'TZ S3.3 Cit 'TG <br />)ontractor's Name -S' License# Phone <br /> IS CERTIFICATE OF 'WORKMAH'S COMPENSATION INSURANCE ON "FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION C � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -- <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT 0 <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C.�N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -" PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE `_-TYPE. O.F _WELL-_-_- -�- CONSTRUCTION SPECIFICATIONS k <br /> Industrial � -"'''""" Cable Tool Dia. of Well Excavation <br /> I <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publ:ic Driven Gauge-of Casing <br /> Irrigation Gravel Pack Depth of ,Grput Seal <br /> Cathodic Protection Rotary Typ�, of Orout <br /> Disposal iOther Other Informati-on <br /> Geophysical I �. Surface Seal Installed by: <br />'UMP INSTALLATION: Contractor., <br /> Type of Pump ...5 .-�._� - -- H. <br />'UMP REPLACEMENT: " " ry ❑State Work Done <br />'UMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material an2 Procedure <br />[ hereby certify that° I have prepared this application and that the work will be done in accordance <br /> vith San' Joaquin County Ordinances , - State Laws , and Rules and Regulations of the San Joaquin Local I <br /> iealth District. Home owner or licensed agent's signature certifies the following: i <br /> "I certify that: in the performance bf ,the work for which this permit is issued, I shall <br /> not employ any-pe-rson..in such manner_ as to become subject to Workman's Compensation <br /> laws of California. " '7 9-7YWAU-i2- <br />[ WILL CALL OR A GROUT IN PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. I <br /> iIGNED TITLE: DATE: S <br /> vDRAW PLOT PLAN ON REVERSE SIDE <br /> FORADEPARTMENT USE ONLY <br />)RASE I 3-?/0 <br /> APPLICATION ACCEPTED BY DATE <br />\DDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III F AL PECTION <br />;NSPECTION BY DATE INSPECTION BYL, rW DATE / <br />'W I A 9 A -0mru 19_77 l 17 7Ma <br />