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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR FFICE USE: 1601 E. Hazelton Ave„ Stockton, CA 95205 Permit No. `7 J-7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued *7-12-7P <br /> ('Complete In Triplicate) " <br /> f <br /> Application is hereby made ,3to the San Joaquin Local Health District .for aermit. to construct <br /> and/or' install the work herein described. This application is made in .compl. iance with San <br /> Joaquin County Ordinance No'! 1862 and the Rules and Regu1ati.ons of the .San Joaquin Local Health <br /> District, A <br /> EXACT, - 3 © CITY/TOWN <br /> - r <br /> Owner's.. Name L/ Phone <br /> Address o z City ` <br /> Contractor's Name License# ZZg Phone ZrJ Z 73 <br /> IS CERTIFICATE .OF WORKMAN'S ,COMPENSATION INSURMICE ON FILE WITH-SJLHD? YES 0- <br /> TYPE` OFWORK (Check) : NEW WELLS] DEEPEN Q RECONDITION ❑ DESTRUCTION[ tN <br /> - WELL CHLORINATION Q WELL ABANDONMENT EDOTHER 0 <br /> } PUMPIINSTALLATION ;_ - PUMP REPAIRS] PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTiC TANK SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOSAIELD CESSPOOL/SEEPAGE PIT OTHER <br /> . . , PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DO�IESTIC 'WELL <br /> INTENDED-USE + TYPE OF.WELL.- CONSTRUCTION SPECIFICATIONS ' <br /> Industria] <br /> Cable Tool Dia. of Well Excavation <br /> _ `Domestic/private Drilled Dia. of Well Casing <br /> Domesi;ic/public Driven Gauge of Casing <br /> Irrigation r Gravel Pack Depth of Grout Sell: <br /> Cathodic Protection Rotary Type of Grout 3` <br /> Disposal Other Other Information <br /> "Geophysical , . Surface Seal Insta ed by: <br /> PUMP INSTALLATION:.. Contractor Al "S <br /> Type 6fH.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> F PUMPREPAIR:_ _ ❑State Work Done <br /> - _ . <br /> DESTRUCTION OF WELL: We11 Diameter <br /> Approximate Depth <br /> -Describe Materia and Proce ure <br /> . I hereby certify that I have prepared this application and that the work will be done in- accordant <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 fnot employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. ', p <br /> I WILL.CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GSIGNEDDATE: <br /> ' TITLE: a4 4-16 <br /> r (bRAW P L 0 T�TLEW ON REVERSE XIDEJ <br /> OR DEPARTMENT USE ONLY /� <br /> PHASE- I A <br /> .APPLI.CATION ACCEPTED-6y9 <br /> DATE 7-1 '71 d <br /> ADDITIONAL -COMMENTS: <br /> ` PHASE II GROUT I PECTION <br /> riNSPECTIONtBY � PHASE I FINAL INSPECTION <br /> DATE INSPECTION BY 01 -ATE <br /> EH 14 '26 Rev. . 9/78 9/.78 M <br />