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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton .,Ave._;, Stockton, CA 95205 Permit No. _ <br /> Telephone: (t09)-`466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - /-;8' <br /> This Permit Ex fres 1'Year From Date Issued <br /> 3 Complete In Tripl,itate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 4 and/or install -the work herein described. This application is made in compliance with San <br /> f �OdgUi� County- Ordinance No:• 1862 and the Rules and. Regulations of the San Joaquin Local Health <br /> ' 'District. <br /> i r <br /> EXACT STREET ADDRESS p d nIVO�� ITY/TOW.N <br /> Owner's Name •/ Phone -(o <br /> Address �?�. O <br /> Ci ty .. <br /> ' Contractor's NameLicense# ,,? Phone <br /> IS CERTIFICATE OF WORKMAN'S'�COMPEN5ATI0�i TABU 1,10E ON FILE WITH SJLHD? YES NO <br /> �...T_Y_PE._OF.,.W.ORK-,(.C.heck-)_:v/,.NEW-.WELLS ---_DEE-PE-N=O- --=R£CONDIT-ION DESTRUCT=ION.[],WELL CHLORINATION p :WELL ABANDONMENT p OTHER <br /> PUMP INSTALLATION 0 .PUMP-, REPRI-R Q 4 ,PUMP REPLACEMENT E) <br /> DISTANCE TO NEAREST: SEPTIC TANK_ j2! SEWER LINES a Pli PRIVY P <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -. PRIVATE DOMESTI•C-WELL`- PUBLIC DOMESTIC WELL <br /> _. <br /> INTENDED USE i5 TYPE OF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well Excavation " -1 <br /> Domestic/private Drilled ; _Dia. of Wel1_ Casing <br /> Domestic/public Driven = Gauge- -of Casing <br /> Irrigation �/�Gravel Pack �0ep�t-h -of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> k Disposal Other �, Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Typeaof Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: '05itate Work Done <br /> DESTRUCTION OF WELL: WellIDiameter Approximate Depth <br /> 4 - .$•--Descri°be-�Mate ri a aii -Prote ure u _ — <br /> I hereby certify that I have prepared this application and that the work will be done in accordan+ <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <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 CAL .. FOR A GROUT INSPECTION. PRIOR TO,-GROUTING AND -A FINAL-'i'NSPECTTON-.` <br /> SIGNED TITLE: DATE: <br /> (DRAW PLET P,Lyri ON REV R E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : L <br /> PHASE II GROUTiINSPE&TION PHASE III FINAL INSPECTION <br /> 11INSPEC'TnIQ,N ,BY DATE - INSPECTION BY DATE //- 07-79 <br /> P4� a;;:F I"(//7 7B °/ala C, ���, 1� e�n�.�'.°J�"" G�I <br /> ru 1n9C D. 1'7_77 - ��S "";del 5 1. 78 <br />