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I <br /> i SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton .Ave. ;. Stockton, CA 95205 Permit -No. �7L-Z6 S y <br /> Telephone: (209)465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 /> hand/or install the work herein described. This application is made in compliance with San <br /> �'oaquin County Ordinance No. 41862 and, the Rules and, Regulations .of the .San J:oaqui-n Local Health <br /> District. <br /> EXACT STREET ADDRESS "' 6, dA1 ," 'CITY/TOWN <br /> Owner' s Name V Sc" Lr( e S s Phone `3 -7 D,Z <br /> -- — . <br /> Address 3 41. Ci ty- 'S"�'�.� <br /> Contractor's Name Otit at a sA,4u License# 6� (o Phone z <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA^SCE Otl FIL£ WITH SJLHD? YES NO <br /> TYPE OF WORK. (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 9?r- PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK(: SEWER LINES PIT PRIVY <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domes.ti_c/.pub-Ii_c-- . :. Dri ven ;-- .- �: Gauge-of-Ca`s-i-ng'`"- _`— <br /> I,-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 /> f PUMP INSTALLATION: Contractor 1,41re iZ S,q,L d� C <br /> Type ofwPump- -- , ,;, - F H.P. _Jr <br /> PUMP REPLACEMENT: ❑$ta e Work' Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter, ' �'�' Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I haveg'prepa.red-_this ,app1ication"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 CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE: T DATE: AG 17P <br /> P <br /> k DRAW PLOT PLAN ON REV SE SIDE <br /> i) FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> ! APPLICATION ACCEPTED BY d� DATE <br /> ADDITIONAL COMMENTS: ;t <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> ',INSPECTION BY DATE INSPECTION BYE DATEr' <br /> IF'H' 1 d9F Pow 19-77 (4/78 2M <br />