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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ZZ,2 7 <br /> Telephone: (209) 466-6781 <br /> F- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 2--.72e <br /> This Permit Expires I 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 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. 9>-&.O ...5. --7-A r.,E "1 <br /> EXACT STREET ADDRESS 7 14, rc «.i / CITY/TOWN7,�. � ' <br /> Owner's Name CkAft1rcolre Phone -- � . <br /> Address city <br /> Contractor' s Name ,� �, Licensee f Phone <br /> r <br /> IS CERTIFICATE OF WORKMAN'S COMIPE SATI41 T"JSURANU ON FILE WITH SJLHD? YES -4- 11140 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ..N.�. <br /> DISTANCE TO NEAREST: SEPTIC TANKAev"f SEWER LINES PIT PRIVY c <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 i <br /> Domestic/private Drilled Dia. of Well Casing 1 <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: Contractorfi�e � ff <br /> Type of Pump H.P. <br /> Trfr /. .. r " <br /> PUMP REPLACEMENT: 99State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 ANDA FINAL INSPECTION. <br /> SIGNED TITLE-.,,6Z,4 DATE• I <br /> DRAW PL T PL N ON REVERSE SIDE ov <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IJ <br /> APPL I CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH J.42.6---Reu-__12.-.77 1/78 2M <br />