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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: .F y 1601 E. Hazelton Ave. , Stockton, CA- 95205 Permit No. 7 -/.3 <br /> Telephone: (209) 466=6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> (complete In Tripl.ica.te) <br /> Application is hereby made to the San Joaquin Local Health .Di,strict 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 Sane-Joaquin Local Health . <br /> I District. <br /> EXACT' STREET ADDRESSCITY/TOWN �.a-� <br /> Owner's NamePhone Sl? 1 --?6 <$-09 J <br /> -- <br /> Address . City <br /> Contractor' s Name License#_�? /I L Phone <br /> PIS CERTIFICATE OF WORKMAN'S 60MIPENSATION INSURAMU N FILE WITH SJLHD? YES 0' <br /> tTYPE,OF WORK (Check) : NEW WELLEN DEEPEN ® RECONDITION DESTRUCTION <br /> WELL CHLORINATION [3 WELL ABANDONMENT C3 OTHER 0 -- O <br /> 3 PUMP INSTALLATION 0PUMP REPAIR PUMP REPLACEMENT Q `1 <br /> 41 <br /> l , <br /> i DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES_1) PIT PRIVY <br /> SEWAGE DISPOSAL rFIELD ° e CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINV& PkIVATEDOMESTIC WELL.-5-4 -A- PUBLIC DTMESTIC WELL <br /> INTENDED USE # TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria _ __X Cable ToolDia. of We 1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> k Domestic/public Driven Gauge of Casing ` <br /> 'Irrigation Gravel Pack Depth of Grout eal 44 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> t -� •.-Geophysical Surface Seal Installed b <br /> kPUMP INSTALLATION: Contractor ` <br /> p Type of Pump H. . <br /> e <br /> ' PUMP REPLACEMENT: r]State Work Done_ <br /> PUMP REPAIR: ❑State Work Done 'r`' s" <br /> , DESTRUCTION OF WELL: Wel-I -Diameter Approximat-e. -Depth-- <br /> Describe Materia and Procedure <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 <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California ....A <br /> I WILL C FOR A- 0 . NSPECT'ION PRIOR TO GROUTING AND A'FINAL INSPECTION.OVY j <br /> S IGNED. - TITLE: --� DATE: {/ :£,�_ <br /> ' (DRAR PLOT PL N ON REVE SI E. _- -. <br /> DE , RTMENT USE ONEY - <br /> CPHASE .I-_ - <br /> rAPPLICATION ACCEPTED BY DATE <br /> A_ 1;W <br /> (ADDITIONAL COMMENTS: <br /> F PHASE II GROUT INSPECTION PHASE III ,INAL INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY W DATE _,�`z8, -7 <br /> r <br /> ;EH 14 26 Rev. 9/78 <br />